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A  PRACTICAL  MANUAL 


OF 


MENTAL  MEDICINE 


BY 


Dr.   E.   RfiGIS 


Formerly  Chief  of  Clinlque  of  Mental  Diseases,  Faculty  of  Medicine,  Paris 
Formerly  Assistant  Physician  of  the  Sainte-Anne  Asylum 
Physician  of  the  Maison  de  Sante  de  Castel  d'Andorte 
Laureate  of  the  Medico-Psychological  Society  and  of  the  Faculty  of  Med- 
icine of  Paris 
Professor  of  Mental  Diseases,  Faculty  of  Medicine,  Bordeaux 

WITH  A  PREFACE 

BY 

M.  BEISTJAMIIS^  BALL 

Clinical  Professor  of  Mental  Diseases,  Faculty  of  Medicine,  Paris 

A  Work  Crowned  by  the  Faculty  of  Medicine  cf  Paris 

Chateauvillard  Prize  1886 


SECOND  EDITION 
Thoroughly  Revised  and  Largely  Re-Wrltten 


AUTHORIZED  TRANSLATION 

BY 

H.  M.  BANNISTER,  A.  M.,  M.  D. 

Late  Senior  Assistant  Physician,  Illinois  Eastern  Hospital  for  the  Insane 

Member  of  the  American  Medico-Psychological  Association 

Member  of  the  American  Neurological  Association 

Member  of  the  American  Academy  of  Medicine,  etc. 

WITH  INTRODUCTION  BY  THE  AUTHOR 


Utica,  N.  Y. 

Pkess  of  American  JotrBKAx  or  Insanitt 

1894 


TO  MY  FATHER 


Dr.  LOUIS  REGIS 


PREFACE 

To  THE  FmsT  Edition. 


The  study  of  mental  disease  has  within  a  few 
years  attained  an  unlooked-for  development.  Its 
corps  of  instruction  has  been  enlarged  by  the  addition 
of  many  chairs,  and  its  literature  enriched  by  numer- 
ous works,  some  of  which,  like  the  recent  volume  of 
Maudsley,  view  the  subject  from  a  philosophical 
and  physiological  point  of  view,  while  others,  like 
the  classic  treatises,  handle  the  subject  on  its  sys- 
tematic side,  and  still  others,  intended  to  familiarize 
students  and  practitioners  with  the  elements  of  men- 
tal medicine,  take  the  more  modest  form  of  manuals. 

This  work  of  M.  Regis  occupies  a  middle  place 
among  these  various  types.  On  the  one  hand  it  rep- 
resents the  manual,  by  its  condensation  of  material, 
its  brevity  and  clearness,  and  by  its  order  and  con- 
ciseness, which  will  be  especially  appreciated  by  those 
who  desire  to  acquire  a  moderate  acquaintance  with 
the  subject  without  devoting  to  it  long  and  labor- 
ious studies.  On  the  other  hand,  it  is  almost  a 
didactic  work  in  the  very  elaborate  manner  in  which 


VI  PEEFACE  TO  FIRST  EDITION. 

the  subjects  of  certain  chapters  are  treated,  and  in 
the  frequent  personal  and  original  views  which  it 
contains.  I  will  mention  in  this  last  connection  the 
attempts  at  classification  which,  following  so  many 
authors,  he  has  sketched,  and  the  chapters  on  hallu- 
cinations, partial  insanity,  sympathetic  insanities, 
and  especially  that  on  general  paralysis. 

The  spirit  which  has  controlled  the  production 
of  this  work  is  before  all  clinical  and  practical. 
Without  disdaining  high  philosophical  conceptions, 
the  author  applies  them  in  general  to  bring  to  the 
front  only  such  subjects  as  will  offer  a  direct  inter- 
est in  point  of  view  of  the  diagnosis,  treatment  and 
government  of  the  patients.  His  book  is,  therefore, 
especially  designed  for  students  who  wish  to  rapidly 
acquire  the  necessary  knowledge  to  properly  com- 
plete their  studies,  and  for  practitioners  who  desire 
the  information  indispensable  to  those  who,  having 
to  do  with  the  insane,  are  not  always  able  to  com- 
mand the  assistance  of  the  skill  of  a  specialist,  which 
is  so  readily  obtained  in  the  great  scientific  centres. 

In  a  general  way,  the  ideas  expressed  in  the  work 
of  M.  Regis,  are  in  accord  with  the  instruction  I 
have  given  for  many  years  in  the  asylum  of  St.  Anne, 
and  in  which,  in  liis  capacity  as  chef  de  clinique,  ho 
has  himself  borne  an  important  part.     The  origin- 


PEEFACE  TO  FIEST  EDITION.  VU 

ality  of  an  independent  mind,  however,  cannot  but 
reveal  itself  in  a  work  like  the  present  one ;  and  it 
is  not  a  servile  copy  of  my  lectures  that  is  here 
offered  to  the  public;  in  many  respects  he  differs 
decidedly  from  the  views  I  have  taught.  I  am  all 
the  more  free,  on  this  account,  to  praise  the  excellent 
spirit  in  which  this  volume  is  conceived,  to  notice  its 
incontestable  merits,  and  to  wish  for  it  a  happy  for- 
tune in  medical  literature. 

Peopessoe  B.  Ball. 


ESTDRODUCTION, 


This  work,  crowned  by  the  Faculty  of  Medicine 
of-  Paris,  and  having  attained  in  a  few  years  its 
second  edition,  has  had  a  success  as  unexpected  as 
it  has  been  undeserved.  Surely  the  least  I  could  do 
towards  a  recognition  of  that  generous  reception  was 
to  subject  my  manual  to  serious  correction  and  adapt 
it,  to  the  best  of  my  ability,  to  the  progress  of 
science.  I  have  therefore  revised  the  entire  book 
thoroughly,  suppressing  superfluities,  modifying 
certain  passages,  adding  new  articles  and  chapters, 
and  aiming  always  to  be  as  practical  as  possible. 
Have  I  succeeded  in  this  task?  It  is  not  for  me  to 
say.  In  any  event  I  hope  that  I  shall  be  credited, 
as  in  the  case  of  the  first  edition,  with  good 
intentions. 

E.  Regis. 
November  14,  1891. 


TUAKSIiATOR'S  NOTE. 


It  is  a  rather  remarkable,  and  perhaps  not  alto- 
gether a  creditable  fact  that,  up  to  the  present,  we  have 
had  no  English  translation  of  any  modern  standard 
French  work  on  mental  diseases  and  their  treatment. 
No  apology  therefore  seems  necessary  for  having 
endeavored  to  present  to  American  readers  the  work 
of  Dr.  Regis  which  is,  as  it  is  considered  in  France, 
a  model  of  its  kind. 

No  alterations  have  been  made,  the  aim  having  been 
to  give  as  far  as  possible  a  literal  translation  of  the 
original.  Two  chapters,  however,  that  appeared  in 
the  French  edition, — those  in  regard  to  the  commit- 
ment of  the  insane  and  their  relations  to  the  civil 
code, — have  been  omitted,  with  the  permission  of 
the  author.  They  referred  exclusively  to  French 
law  and  usage,  and  hence  their  practical  value  could 
not  be  conveyed  into  an  American  translation. 

n.  M.  B, 

CniCAGO,  103  State  St., 
July,  1S94 


AUTHOR'S  PREFACE  TO  TRANSJLATION. 


On  dit  communement  que  la  Science  n'  a  pas  de  frontiSres. 
Cet  aphorisme,  vrai  peut-6tre  pour  quelques  unes  des  con- 
naissances  humaines,  ne  I'etait  certainement  pas  il  y  a  quel- 
ques annees  encore,  ];)Out  la  psychiatrie.  Jusqu'^  ces  der- 
niers  temps,  en  effet,  chaque  pays  a,  pour  ainsi  dire,  cul- 
tive  isolement  les  maladies  mentales,  ayant  d  cet  egard  ses 
traditions,  ses  vues  particuli^res,  ses  methodes  cliniques  et 
therapeutiques  et  jusqu'  k  sa  terminologie,  II  en  resultait 
un  manque  de  cohesion  dans  les  efforts  et  un  retard  dans  le 
progr^s. 

Aujourd'hui,  nous  comprenons  mieux  la  necessite  de  ne 
pas  rester  livres  t  nos  propres  forces  et  de  nous  tenir  au 
courant  des  travaux  internationaux,  soit  par  des  analyses, 
soit  par  des  traductions  reciproques.  Ce  mouvement  de 
collaboration  universelle  a  dejd  produit  de  bons  resultats  et 
11  en  produira  de  meilleurs  encore  dans  1'  avenir. 

La  traduction,  sur  la  deuxiSme  edition  frangaise,  de  mon 
Manuel  pratique  de  medecine  meniale,  doit  etre  consideree 
sans  doute  comme  une  des  manifestations  de  ce  besoin  gen- 
eral de  se  connaitre  et  de  s'entendre  entre  ouvriers  separes 
d'une  oeuvre  commune.  Je  n'  y  vois  pas  d'autre  raison  en 
tout  cas,  n'ayant  pas  la  presomption  de  croire  ^  mon  livre 
assez  de  valeur  pour  s'  imposer  par  ses  qualites  personnelles, 
^  I'attention  de  1'  etranger. 

En  France  il  a  eu  quelque  succSs,  par  ce  qu'il  essayait  de 
presenter  sous  une  forme  t  la  fois  methodique,  claire  et  con- 


siv        AirrnoE's  tkefacb  to  tka:n-slatton. 

else,  nos  connaissanccs  les  plus  importantcs  en  psycliiatrie, 
mcdicale  ct  medico-legale.  Anra-t-il  ]a  mume  fortuQC  aux 
Etats-Unis  ?  Jc  n'ose  mc  laisser  aller  a  cette  illusion  ct 
je  m'estimerai  lieurcux  s'  il  y  obtient  seulcment  un  accueil 
quel  que  peu  sympathique. 

Quel  que  soit  Ic  degre  de  faveur  qu'il  puisse  rencontrer, 
je  dois  declarer  tres  sincerement  qu'  il  la  devra  tout  enti^ro 
3,  ses  intei'pretes  americains :  au  savant  Dr.  Bannister,  qui  a 
realise  une  irreprocliable  traduction,  tant  par  la  forme  que 
par  le  fond ;  au  Dr.  Alder  Bluraer,  1'  eminent  publiciste, 
qui  a  con9u  I'lieureuse  idee  de  faireimprimer  le  livre  t 
I'asile  d'  Utica,  par  ses  maladcs,  et  de  lui  donner  cette  appar- 
cnce  elegante  et  coquette  sous  laquclle  il  se  presente  icL 
C'est  la  premiere  fois  assurement,  qu'un  ouvrage  traitant 
d'  alienation  mentale,  se  trouvc  a  la  fois  ecrit  par  un  alien- 
istc,  traduit  par  un  alienistc  et,  sous  la  direction  d'  un 
alieniste,  imprime  ct  relie  par  des  alienes.  Puisse-t-il,  pour 
Ctre  complet  a  cc  point  de  vue,  etrc  lu  et  goute  par  les 
alienistcs  des  Etats-Unis!     C'est  la  mon  voeu  de  la  fin. 

Je  m'  en  remets  pour  cela  a  mes  excellents  confreres,  les 

Drs.  Bannister  ct  Alder  Blumer,  d  qui  je  seiTC  les  mains  par 

delil  les  mers,  en  les  remerciant  bicii  cordialemcnt  de  lour 

precicux  conGOurs. 

E.  RiiGIS. 
Bordeaux,  17  fevricr,  1894. 


[It  is  a  common  remark  that  science  recognizes  no  fron- 
tiers. This  aphorism,  true  perhaps  for  some  branches  of 
human  knowledge,  certainly  has  not  been  true  within  a 
comparatively  recent  period  for  psychiatry.    Up  to  within 


AUrnOE's  PREPACE  TO  TEANSLATION.  XV 

a  few  years,  indeed,  each  country  has,  so  to  speak, 
Btudied  mental  disorders  by  itself  alone,  having  in  this  re- 
gard its  own  special  traditions,  its  own  particular  views, 
clinical  and  therapeutic  methods,  and  even  its  own  teimin- 
ology.  The  result  has  been  a  lack  of  unity  of  effort  and  a 
hindrance  to  progress. 

To-day  we  better  appreciate  the  necessity  of  not  confining 
ourselves  to  our  own  investigations  and  of  keeping  ourselves 
in  touch  with  foreign  workers,  either  by  means  of  abstracts 
and  reviews  or  by  reciprocal  translations.  This  tendency 
to  universal  collaboration  has  already  given  us  good  results 
and  will  produce  still  better  ones  in  the  future. 

This  translation  of  the  second  French  edition  of  my 
Practical  Manual  of  Mental  Medicine  should  without  doubt 
be  considered  as  one  of  the  manifestations  of  this  general 
desire  of  workers  in  a  common  field  to  know  and  understand 
each  other.  I  can  see  no  other  reason  in  any  case,  not 
having  the  presumption  to  believe  my  book  of  such  value 
as  to  impose  itself  by  its  own  merits  upon  the  attention  of 
forc-ign  readers. 

In  France  it  has  met  with  some  success  as  an  attempt  to 
present  in  a  form  at  once  methodic,  clear  and  concise  the 
more  important  facts  of  our  knowledge  of  medical  and 
medico-legal  psychiatry.  Will  it  have  the  same  good  for- 
tune in  the  United  States?  I  do  not  permit  myself  to  in- 
dulge in  this  illusion  and  will  consider  myself  fortunate  if 
it  obtains  only  a  moderately  sympathetic  reception. 

Whatever  favor  it  may  meet,  I  ought  to  say  will  be  due 
to  its  American  sponsors:  to  Dr.  Bannister,  who  has  made 
fin  irreproachable  translation,  both  as  to  letter  and  substance ; 


Xvi     AUTHOE*S  PREFACE  TO  TEANSLATION. 

and  to  its  eminent  publisher,  Dr.  Alder  Blumer,  who  con- 
ceived the  happy  idea  of  having  it  printed  at  the  Utica 
asylum  by  his  patients  and  who  has  devised  for  it  the  neat 
and  elegant  appearance  it  here  presents.  It  is  assuredly  the 
first  instance  of  a  work  treating  of  mental  alienation,  writ- 
ten by  an  alienist,  translated  by  an  alienist,  and,  under  the 
direction  of  an  alienist,  printed  and  bound  by  the  insane. 
May  it  not,  to  carry  the  point  to  completion,  be  read  and 
approved  by  the  alienists  of  the  United  States.  This  is  my 
prayer  for  its  future. 

I  leave  it  for  this  to  my  excellent  confreres,  Drs.  Bannister 
and  Alder  Blumer,  to  whom  I  stretch  my  hand  across  the 
seas,  cordially  thanking  them  for  their  valuable  assistance. 

E.  rI:gis.] 

Bordeaux,  February  17,  1894. 


A   PRACTICAL  MANUAL 

OF    MEKTAL    MEDICII^E. 


PART   FIRST 
MENTAL    PATHOLOGY. 


HISTORICAL. 

In  order  to  begin  the  study  of  mental  alienation 
with  profit,  it  seems  necessary  to  summarize  briefly 
the  history  of  its  progress  down  the  centuries. 

This  history  of  insanity,  view^ed  as  a  whole,  in- 
cludes four  distinct  epochs. 

The  first  or  primitive  epoch  is  that  period  of 
ignorance  and  superstition  prior  to  any  medical 
ideas,  in  which  insanity  was  considered  as  coming 
from  the  gods,  and  its  treatment  confided  to  the 
priests.  It  extended  from  the  beginning  of  the 
world  down  to  Hippocrates,  who  marks  the  advent 
of  a  new  era,  and  with  whom  begins  mental  medi- 
cine properly  so-called. 

The  second  epoch  is  the  classic  medical  epoch, 
which  starts  from  Hippocrates  and  ends  with  the 
Roman  decadence,  after  having  successively  passed 
through  three  brilliant  periods:  the  Hippocratic 
period,  the  Alexandrine  period  and  the  Grseco- 
Roman  period. 


2  HISTORICAL. 

The  third  epoch  or  epoch  of  transitio)i ^  the  be- 
ginning of  which  is  marked  by  the  return  to  the 
primitive  superstitions  adapted  to  the  requirements 
of  a  new  religion,  and  which  did  not  begin  to  be 
dispelled  until  towards  the  last  days  of  its  history, 
also  includes  two  periods:  the  middle  ages  and  the 
Renaissance.  It  extends  from  the  commencement  of 
the  Christian  era  to  the  end  of  the  eighteenth  cen- 
tury, that  is  to  say,  from  Coelius  Aurelianus  and 
Galen  down  to  Pinel. 

The  fourth  or  modern  epoch  is  that  scientific 
period  jkit  excellence^  which  commences  Avith  Pinel, 
that  is,  from  the  great  and  memorable  reform  of 
1793,  was  continued  with  Esquirol  and  his  students, 
and  may  be  considered  at  the  present  time  to  be 
attaining  gradually  its  apogee. 

Such  are  the  principal  stages  in  the  history  of  in- 
sanity. It  is  now  necessary  to  pass  in  review  and 
notice  briefly  the  principal  facts  relative  to  each. 

FIRST  EPOCH. 

{Primitive  epoch). 

If  there  is  one  well  established  liistorical  fact,  it 
is  that  of  the  predominance  of  the  divine  idea  in  the 
beginnings  of  society.  All  peoples  in  their  infancy 
have  submitted  to  the  exclusive  yoke  of  a  religious 
belief  to  the  extent  that  it  seems  as  if  superstition 
was  necessarily  one  of  the  first  phases  of  their  evolu- 
tion.    In  the  first  periods  of  existence  everything  is 


PRIMITIVE    EPOCH.  6 

referred  to  celestial  intervention,  and  insanity  itself 
was  considered  by  them  as  the  possession  of  the  in- 
dividual by  a  benevolent  or  avenging  divinity. 

It  was  thus  w^ith  the  Jews,  as  is  evidenced  by  the 
episodes  of  the  maniacal  behavior  of  king  Saul  and 
the  attack  of  lycanthropy  of  Nebuchadnezzar. 

We  find  analogous  beliefs  and  practices  among  the 
Egyptians.*  There  is  in  the  Bibliotheque  of  Paris, 
an  Egyptian  stele  dating  from  the  third  century  B.C., 
the  inscription  on  which  gives  the  account  of  an 
Asiatic  princess  possessed  by  a  spirit,  w^ho  was  cured 
by  the  intercession  of  the  god  Khons.  We  know 
also  that  there  existed  in  Egypt  temples  dedicated 
to  Saturn  where  they  purified  the  insane  with  the 
y)urpose  of  restoring  them. 

In  ancient  Greece  the  condition  was  the  same,  and 
the  names  daLfiov(DXrjnrot^  deoXTjuTOL^  evepyovfievot, 
deniofiiacs,  possessed  of  the  c/ods,  energumenes^ 
which  were  given  to  those  deprived  of  reason,  show 
plainly  enough  to  what  origin  was  attributed  their 
insanity. 

Everyone  is  acquainted  with  the  history  of  the 

*The  restricted  size  of  this  book  forbids  us  from  citing 
on  each  page  all  the  authors,  French  and  foreign,  to  whom, 
we  are  indebted  for  ideas  or  expressions,  and  we  can  only 
refer,  for  the  bibliography  of  each  chapter,  to  special  treat- 
ises and  articles  in  the  Dictionnnires.  We  cannot  refrain, 
however,  from  saying  how  much  we  have  been  aided  in  the 
preparation  of  this  history,  by  the  publication  of  the  works 
of  Trelat,  Las^gue  and  Morel,  Marce,  Ball,  and  especially  the 
excellent  work  of  Semelaigne. 


4  HISTORICAL. 

unhappy  Mcleager,  with  that  of  the  parricide  Orestes, 
and  those  not  less  celebrated  of  the  daughters  of 
Pretus,  king  of  Argos,  who,  afflicted  by  Juno  with 
a  sort  of  lepra,  believed  themselves  transformed  into 
cows  and  lowed  in  imitation  of  those  animals. 
Tradition  relates  that  they  were  cured  by  the  shep- 
herd Melampus  with  the  aid  of  hellebore,  purifica- 
tions and  religious  ceremonies. 

The  insane  were  not  ahvays  considered,  neverthe- 
less, as  the  prey  of  the  infernal  divinities.  Among 
them  were  found  some,  who,  by  reason  of  their 
delusive  exaltations,  passed,  on  the  other  hand,  as 
friends  of  the  gods,  as  inspired,  and  who  prophesied 
the  future.  Among  these  last  the  Delphian  pyth- 
oness is  one  of  the  most  celebrated.  With  such 
beliefs  as  to  the  nature  of  insanitj^,  the  treatment 
of  the  insane  ought  clearly  to  consist  in  religious 
ceremonies  and  to  be  confided  to  the  priests.  This 
is  what  occurred.  In  Greece  the  Asclepiades,  a  sort 
of  medicai  priests,  who  managed  the  temples  of 
^sculapius,  were  specially  charged  with  their  cure. 
Hippocrates,  Avho  later  scored  these  charlatan  priests 
and  denounced  their  curative  practices  in  which 
speculation  evidently  played  the  principal  part,  has 
left  us  a  detailed  account  of  their  treatment  of  the 
insane. 

The  ceremony  had  for  a  prelude  an  adjuration  to 
the  malignant  deity;  they  besought  it  to  depart 
from  the  body  of  the  possessed.  After  this,  the 
patient  was  submitted  to  purifications,  expiations, 


PRIMITIVE    EPOCH.  5 

exorcisms,  ablutions  with  the  lustral  water  or  the 
blood  of  a  sacrificial  victim. 

Occasionally  there  were  added  to  these  religious 
ceremonies  some  wise  hygienic  practices :  spectacles, 
recreations,  music,  promenades,  sojourns  at  thermal 
baths  and  exercise  in  the  gymnasium.  It  thus  hap- 
pened that  some  of  the  patients  were  cured,  and  this 
was  then  attributed  at  once  to  the  appeasement  of 
the  offended  deity,  and  necessarily  involved  the 
o-ivino-  of  valuable  offerins^s,  to  the  enrichment  of 
the  priests. 

Such,  in  the  early  ages,  were  the  prevalent  ideas 
in  regard  to  insanity  and  the  means  employed  for  its 
cure.  We  shall  have  to  pass  rapidly  over  this 
rather  confused  period  of  the  history  of  mental 
disease,  and  merely  mentioning  the  Pythagorean 
philosophers  who,  in  the  fourth  and  fifth  centuries 
before  Christ,  received  from  the  priests  the  notions 
they  possessed  to  only  confuse  them  sometimes  with 
philosophy,  sometimes  with  physics  and  metaphys- 
ics, we  come  to  Hippocrates,  with  whom  really 
commences  the  medical  science  of  antiquity. 

SECOND  EPOCH. 

{Medical  epoch  of  antiquity). 

1.     HirpocRATic  Peiuod. 

Hippocrates,  the  creator  of  mental  medicine,  be- 
longed to  a  family  of  priests,  the  Asclepiades,  who 


6  HISTOEICAL. 

claimed  descent  from  ^sciilapins  and  possessed,  as 
we  have  seen,  the  monopoly  of  the  treatment  of  the 
insane  in  ancient  Greece. 

He  was  born,  as  is  well  known,  in  the  island  of 
Cos,  460  B.  C.  Although  he  wrote  no  special  treat- 
ise on  mental  alienation,  it  is  easy  to  perceive  from 
an  attentive  perusal  of  his  writings,  that  he  had  a 
tolerablv  accurate  knowledoe  of  this  class  of  dis- 
orders.  E^'en  before  him  some  distinctions  had  been 
made,  as  he  appears  to  have  borro\\'ed  from  tradition 
the  tei'ms  he  employed  of  ])hrenitis,  mania,,  melan- 
cholia and  sacred  disease. 

Hippocrates  describes  phrenitis  according  to  its 
etymology,  together  with  pleuritis  and  pneumonia, 
and  locates  its  seat  in  the  phrenic  center.  It  con- 
sists, according  to  him,  in  a  continuous  delirium 
in  an  acute  fever.  Its  cause  is  the  heating  of  the 
whole  body  by  the  blood,  itself  over-heated  by  mix- 
ture with  the  bile  which  displaced  it  and  changed  it 
to  serum,  affected  its  movement  and  its  habitual  con- 
stitution. As  to  the  symptoms,  they  are  fully  indi- 
cated in  the  following  formula,  as  succinct  as  accurate, 
which  is  taken  from  the  treatise  on  ej)idemic  affec- 
tions :  "Acute  delirium  with  high  fever,  carphologia, 
small  and  wirv  i)ulse."  The  disease,  the  duration  of 
\vhi(;h  varied  between  the  extreme  limits  of  three 
and  one  hundred  and  twenty  days,  ended  in  death 
more  often  than  in  recovery. 

Although  it  is  diHicidt  t<»  say  exactly  wliat  Hippo- 
crates   and    otlier    ancient    writers    understood    by 


HIPPOCEATIC  PERIOD.  7 

phrenitis^  it  is  allowable  to  conjecture  that  they  in- 
cluded under  this  term  the  majority  of  the  acute 
idiopathic  or  symptomatic  insanities,  and,  in  particu- 
lar, acute  febrile  delirium. 

If  the  indications  relative  tophrenitis  lack  clearness 
in  the  Hippocratic  writings,  this  is  still  more  the 
case  in  regard  to  mania.  Scientifically  the  ancient 
authors,  including  Hippocrates,  considered  mania  as 
a  violent  delirium,  either  acute  or  chronic.  In  the 
Hippocratic  collection  we  find  it  generally  confounded 
with  phrenitis  and  melancholia. 

Melancholia  also  lacked  any  very  precise  significa- 
tion. Its  two  principal  characters,  according  to 
Hippocrates,  seem  to  have  been  fear  and  sadness. 
The  syndrome  varied  also  according  to  whether  the 
alteration  in  the  brain  was  due  to  the  phlegm  or  the 
bile.  If  the  first,  there  was  no  excitement,  if  the 
second,  this  general  condition  was  in  different  degrees 
the  principal  character  of  the  malady. 

Besides  phrenitis,  mania  and  melancholia,  Hippo- 
crates appears  to  have  recognized  the  insanity  of 
pregnancy  and  alcoholic  insanity.  In  any  case  he 
seems  to  have  observed  examples  of  these. 

In  the  domain  of  nervous  diseases  he  possessed 
some  vague  notions  about  hysteria,  but  it  is  epilepsy 
that  he  was  best  acquainted  with,  and  which  he 
described  with  the  greatest  care.  He  even  remarked 
the  fact  that  epilepsy  might  be  complicated  by 
insanity. 

Hippocrates  had  not  merely  the  merit  of  first  rec- 


8  HISTORICAL. 

oguizing  the  pathological  nature  of  insanity.  With 
the  most  praiseworthy  persistence  he  combated 
the  medico-religious  practices  of  the  Asclepiades  in 
order  to  substitute  for  them  a  more  rational  and 
medical  treatment.  From  that  time  the  ablutions, 
exorcisms  and  incantations  were  succeeded  by  phle- 
botomy, purgation,  emetics,  baths,  vegetable  diet, 
hygienic  exercises,  music,  traveling,  in  a  word  by 
all  the  medical  appliances  available  at  that  epoch. 
It  was  he  who  regulated  the  use  of  hellebore 
(Veratrum  album)  employed  enipiricall^^  from  a 
very  high  antiquity  as  a  specific  for  insanity,  and  he 
had  his  patients  go  and  collect  it  themselves  at 
Anticyra,  a  little  village  in  Thessaly,  where  was 
found  the  variety  in  most  repute.  Hippocrates  ap- 
pears to  have  likewise  employed  mandragora,  as  a 
special  drug,  in  cases  of  suicidal  melancholia. 

As  to  how  they  managed  the  insane,  whether  or 
not  there  existed  especial  establishments  for  their 
care,  and  whether  restraint  or  coercion  was  em- 
ployed in  severe  and  difficult  cases,  we  are  unfortu- 
nately left  only  to  conjecture.  It  seems  probable 
that  quiet  and  inoffensive  patients  were  left  at 
liberty  or,  at  least,  in  their  homes  under  the  surveil- 
lance of  their  servants  or  relatives,  and  that  certain 
cases  were  cared  for  in  asylums  {Idrpio)^  as  ap])ears  to 
be  the  case  from  a  passage  in  Plutarch  relative  to 
Antiphon,  a  |»hysician  at  Corinth.  Moreover,  a 
history  of  a  lunatic  related  by  Herodotus  leads  us 
to  suppose  that  very  rigorous  methods  of  restraint 


ALEXANDRIAN    PERIOD.  9 

were  employed  by  the  ancients  in  the  treatment  of 
dangerous  cases.  Pie  says,  in  fact,  that  Cleomenes, 
king  of  Laceda^mon,  having  fallen  into  a  frenzy, 
with  violent  agitation,  his  family  had  him  secured 
by  wooden  fetters. 

Hippocrates  b}"  himself  alone,  as  regards  the  his- 
tory of  insanity,  comprises  or  covers  the  whole 
Hippocratic  period.  His  successors,  who  were  only 
his  imitators,  added  nothing  to  his  medical  ideas  on 
insanity,  and,  at  the  time  of  the  dismemberment  of 
the  empire  of  Alexander,  scientific  tradition  found 
itself  transported  into  Egypt,  where  it  assumed  a 
certain  brilliancy  under  the  reign  of  the  Ptolemies. 

2.     Alexandrian  Peeiod. 

The  Alexandrian  period,  represented  especially  b}" 
Herophilus  and  Erasistratus,  who  lived  about  three 
hundred  years  prior  to  the  Christian  era,  is,  in  reality, 
onl}^  an  intermediate  period  between  Hippocrates  or 
the  Greek  school  and  Asclepiades  and  Celsus  or  the 
Graeco-Roman  school. 

Lacking  documents  in  regard  to  this  period,  its 
history  is  very  obscure,  and  we  are  compelled  to  seek 
what  we  can  learn  from  Galen,  the  works  of  Erasis- 
tratus and  Herophilus  not  having  come  down  to  us. 
But  from  what  we  learn  of  the  scientific  knowledge 
of  these  celebrated  men  and  the  progress  they  had 
attained,  especiall}^  in  anatomy  and  nerve  physiology, 
we  can  believe  that  they  possessed  rather  accurate 
and  extensive  knowledge  of  insanity,  and  that  they 


10  HISTORICAL. 

had  taken  up  and  developed  in  this  regard  the  ideas 
of  the  father  of  medicine. 

About  a  century  later,  under  Ptolemy  Evergetus 
II,  the  scientific  movement  passed  from  Alexandria 
to  Rome,  thanks  to  the  discords  occurring  in  the 
family  of  the  Lagides  and  the  dispersion  of  learned 
men  that  followed  it.  But  it  was  more  especially 
after  the  victory  of  LucuUus  and  of  Pompey  in 
Asia,  that  this  movement  became  prominent  in  the 
Roman  Empire. 

3.     Gr^co-Roman  Peuiod. 

This  period  of  the  history  of  insanity  is  merely 
represented  by  the  names  of  Asclepiades,  Celsus, 
Aretaeus,  Soranus,  Ccelius  Aurelianus  and  Galen. 
It  ended  with  Alexander  of  Tralles,  Paul  of  Egina, 
and  the  Arabs  who  form  a  transition  between  the 
ancient  world  and  the  middle  ages. 

Asclepiades  of  B^^thinia  (80  B.  C),  at  first  a 
rhetorician,  then  a  physician,  an  eminent  partisan 
of  the  philosophical  theory  of  atoms,  established 
formally  the  line  of  demarcation  of  insanity  ad- 
mitted imi)licitly  by  Hippocrates,  and  dating  from 
him  authors  divided  it  into  ac-iUe  alienation  with 
fever  and  phrenitis,  and  dironic  alienation  without 
fever,  or  mania  and  melancholia.  Asclepiades  also 
studied  the  apperceptions  (visa),  and  distinguished 
them   very  clearly  into  hallucinations  and  illusions. 

Finally,  the  fact  of  the  transformation  of  one 
l(niii  of   insanity  into  another  struck  his  attention, 


GE^CO-ROMAN    PERIOD.  11 

and  it  is  probably  under  tlie  influence  of  this  observa- 
tion that  he  came  to  attempt  substitutive  medication, 
and  especially  to  advise  intoxication  in  the  general 
treatment  of  mental  alienation. 

Celsus  (A.  D.  5),  devoted  to  insanity  only  a  few 
pages.  In  place  of  the  general  term  alienatio 
mentis  employed  by  Asclepiades,  he  used  the  term 
insania^  which  he  applied  to  the  three  species  com- 
prised in  his  classification,  namely:  frenzy  (acute 
insanity),  melancholia  which  he  attributed  to  black 
bile,  and  lastly,  a  third  form  which  he  divided  into 
two  sub-species:  1,  hallucmatory  insanity ^  gay  or 
sad  without  delirium  (imaginibus  non  niente  fallun- 
tur) ;  2,  general  and  partial  delirium  (animi  desi- 
piunt) . 

Celsus  went  more  at  length  into  the  subject  of 
therapeutics  and  formulated  some  ver}^  wise  and 
judicious  rules  as  to  hygienic  and  moral  treatment. 
Unfortunately  there  is  a  shadow  in  the  picture, 
since  he  advises  the  use  of  hunger,  chains  and 
chastisements  to  subjugate  the  victim  of  insanity 
when  his  acts  or  his  words  evidence  his  want  of 
reason.  "  Ubi  perperam  dixit  aut  fecit,  fame,  vin- 
culis,  plagis  coercendus  ist." 

Aretaeus  of  Cappadocia,  (A.  I).  80),  belonged 
to  the  sect  of  the  pneumatists.  His  greatest  title  to 
renown  is  that  he  has  left  behind  him  very  remarka- 
bly accurate  and  ti'uthful  descriptions  of  the  various 
forms   of    mental  alienation,   and  especially  mania 


12  HISTORICAL. 

and  melancholia.  He  considered  melancholia  as  a 
mental  depression  with  concentration  of  thought  on 
one  fixed  idea,  without  fevei":  "  Melancholia  in  una 
re  aliqua  est  lapsus,  constante  in  reliquis  judicio. 
Animi  angorinuna  cogitatione  di  fixus  atque  inhoer- 
ens,  absque  febre  et  furore  a  phantasmate  melan- 
colico  ortus."  It  was,  therefore,  according  to  him,  a 
circumscribed  insanity  with  limited  delusion,  in  which 
respect  it  was  different  from  mania,  which  he  con- 
sidered to  be  a  generalized  disorder  of  the  intelli- 
gence. 

Aretaeus  described  melancholia  at  length  and  very 
clearly,  and  noted  especiall}'  the  bodily  symptoms, 
such  as  constipation,  scantiness  of  urine,  eructations, 
fetor  of  the  breath,  small ness  of  the  jjulse,  etc. 

As  regards  mania,  he  considered  it,  as  has  already 
been  said,  as  a  general  continuous  insanit}^  without 
fever,  and  he  distinguished  it  from  the  toxic  delirium 
produced  by  wine,  mandragora  and  hyoscyamus  by 
the  fact  that  these  latter  have  a  sudden  onset 
and  equally  sudden  disappearance,  while  mania  is 
stable  and  permanent.  In  his  description  of  mania 
he  notes  the  mental  exaltation  which  in  some  patients 
quickens  the  faculties  of  memory  and  imagination  so 
that  they  converse  on  astronomy  and  philosophy  and 
compose  poetry  apparently  beyond  their  normal 
ability. 

Aretaeus  shows  in  a  numl)(*r  of  places  in  his 
writings  that  melancholia  is  a  commencement  or  a 
species  of  demi-mania,  and  that  on  the  otliei-  hand 


GK^CO-ROMAN   PERIOD.  13 

when  it  tends  to  subside,  it  sometimes  changes  into 
mania  rather  by  its  progress  than  by  the  intensity  of 
the  disease.  He  also  remarked  the  fact  that  an 
attack  of  mania  may  be  followed  by  a  period  of 
depression. 

That  part  of  the  work  of  Aretaeus  devoted  to  the 
treatment,  and  especially  that  of  the  treatment  of 
maniacal  delirium,  has  not  come  down  to  us.  We 
may  presume,  nevertheless,  from  what  indications 
we  have,  that  since  the  time  of  Celsus  a  reaction 
had  taken  place  in  favor  of  the  insane  since  Aretaeus 
nowhere  mentions  restraints  or  ligatures  in  his 
descriptions  of  even  furious  cases  of  frenzy. 

SoRANus  of  Ephesus  (A.  D.  95),  whose  works  have 
been  lost,  is  only  known  to  us  through  Ccelius 
Aurelianus  who  appears  in  his  writings  as  his  trans- 
lator and  commentator. 

It  is  impossible  to  say  what,  in  the  admirable 
work  of  Coelius  Aurelianus,  properly  belongs  to 
the  author  and  what  must  be  credited  to  the  com- 
mentator. It  is  probable,  nevertheless,  that  Coelius 
Aurelianus  has,  on  a  great  number  of  points, 
expressed  his  own  personal  opinions. 

Ccelius  Aurelianus  lived  about  a  century  after 
Soranus,  of  whom  he  was,  as  seen,  the  translator  and 
commentator. 

In  a  point  of  view  of  mental  pathology,  strictly 
speaking,  Coelius  Aurelianus  has  added  but  little  to 
the  magnificent  descriptions  left  by  Aretoeus;    his 


14  HISTORICAL. 

work  is  limited  to  perfecting  in  a  number  of  points, 
the  ideas  of  his  predecessor.  Thus  he  remarks  the 
distinction  between  frenzy  or  febrile  delirium  and 
mental  alienation  pro})erly  so-called,  and  he  insists 
on  the  organic  disorders  that  accompany  melancholia, 
in  regard  to  which  he  says  :  "In  melancholicis 
stomachus,  in  furiosis  vero  caput  afficitur." 

It  is  especially,  however,  the  chapter  relative  to 
the  treatment  of  insanity  that  forms  the  most  valu- 
able part  of  the  work  of  Ccelius  Aurelianus.  It 
gives  an  admirable  exposition  of  the  rules  of  the 
physical  and  moral  treatment  of  the  insane,  an  elo- 
quent plea  for  gentle  measures  and  consequently  for 
the  suppression  of  coercive  methods,  in  a  word,  a 
full  statement  of  that  method  which  has  been 
revived  in  our  day  under  the  title  of  J^on-restraint. 
Coelius  Aurelianus  expresses  himself  forcibly  in 
regard  to  those  physicians  who  have  recourse  to 
severe  methods  of  treatment.  One  passage  in  ]»ar- 
ticular  deserves  to  be  quoted  :  "  They  seem  rather 
to  lose  their  own  reason  "  says  he  of  these  physicians, 
"  tlian  to  be  disposed  to  cure  their  patients,  when  they 
liken  them  to  wild  beasts  who  must  be  tamed  by  the 
deprivation  of  food  and  the  torments  of  thirst. 
Misled,  doubtless,  by  the  same  error,  they  advise  the 
inhuman  use  of  chains,  not  considering  how  their 
members  may  be  lacerated  or  broken  and  how  much 
better  it  is  to  control  by  the  hands  of  men  than  by 
the  often  useless  weight  of  iron.  They  go  so  far  as 
to  counsel  bodily  violence  and  blows,  as  if  to  compel 


GR^CO-KOMAN    PERIOD.  15 

the  return  of  reason  by  such  provocations,  a  deplor- 
able method  of  treatment  that  can  only  aggravate  the 
patients'  condition,  injure  them  physically,  and  offer 
to  them  the  miserable  remembrance  of  their  suffer- 
ings whenever  they  recover  the  use  of  their  reason." 
In  another  passage  Ca'lius  Aurelianus  says  further, 
after  advising  that  the  difficult  and  disturbed  cases 
be  cared  for  by  skilled  attendants  :  "If  the  sight  of 
other  persons  irritates  them,  and  only  in  very  rare 
cases,  restraint  by  tying  may  be  employed,  but  with 
the  greatest  precautions  without  any  unnecessary 
force,  and  after  carefully  protecting  all  the  joints 
and  with  special  care  to  use  only  restraining  appara- 
tus of  a  soft  and  delicate  texture,  since  means  of 
repression  eraploj^ed  without  judgment  increase 
and  may  even  give  rise  to  furor  instead  of  repressing 
it."  One  could  hardly  plead  better  in  the  cause  of 
humanity  or  lay  down  wiser  rules  on  the  subject  of 
the  means  of  restraint  for  the  insane. 

Galen  (A.  D.  150)  the  celebrated  physician  of 
Pergamus,  who  wrote  five  hundred  memoirs  and 
whose  ideas  had  an  immense  influence  on  his  own 
times  and  retained  the  same  during  the  following 
fourteen  centuries,  gave  a  little  attention  to  the 
subject  of  mental  alienation.  The  leading  point  in 
his  writings  in  this  regard,  is  the  division  he  made 
between  idiopathic  insanit}^  and  sym|)athetic  in- 
sanity'', or  insanity  by  consensus,  and  the  importance 
he  accords  to  the  latter  in  his  descriptions. 


16  HISTORICAL. 

After  Galen  everything  fell  into  obscurity  and 
confusion.  Alexander  of  Tralles  (A.  D.  560)  and 
Paul  of  Eoina  (A.  D.  630)  brought  out  nothing  new 
in  regard  to  insanity,  and  as  to  the  Arab  physicians 
Avecenna,  Rhazes  (10th  century)  they  confined  them- 
selves to  developing  the  ideas  of  Galen  as  to  insanity 
by  consensus,  the  seat  of  which  they  placed  in 
different  viscera,  and  especially  in  the  liver  and 
spleen. 

THIRD  EPOCH. 
{Epoch  of  transition). 

1.     The  Middle  Age*. 

During  the  whole  duration  of  the  middle  ages  the 
study  of  insanity  lost  itself  in  the  general  chaos  and 
no  traces  of  it  were  to  be  found.  The  belief  in 
demons  dominated  all  imaginations;  superstition 
spread  itself  in  all  parts ;  it  was  the  reign  of  sorcery, 
of  the  witches'  Sabbath,  of  demonopathy,  of  lycan- 
thropy  and  of  demoniac  possession. 

Thus  occuiTcd  in  all  parts,  those  terrible  epidem- 
ics of  hysterical  religious  insanity,  the  detailed  his- 
tory of  which  Calmeil  has  preserved,  all  of  which, 
after  a  series  of  exorcisms,  and  of  more  or  less  sol- 
emn mystical  ceremonies,  ended  in  the  condemnation 
of  the  unfortunate  insane  and  their  ])unishmcnt  by 
torture  or  execution.  Thousands  of  unhappy  beings, 
victims  of  popular  prejudice,  atoned  witb  their  lives 
for  their  loss  of  reason  and  became  the  prey  of  the 


THE    RENAISSANCE.  17 

flames.  Not  a  single  voice  was  raised  in  their  be- 
half, the  parliaments  themselves  were  the  most  blood- 
thirsty in  this  barbarous  slaughter,  and  we  have  to 
come  down  to  the  fifteenth  century  to  take  up,  in 
the  point  of  view  of  the  history  of  mental  medicine, 
the  chain  so  long  interrupted.  Religious  delusions 
were  then  still  firmly  rooted,  for  the  first  physicians, 
among  them  Ambrose  Pare  himself,  despite  the  timid 
protests  of  Nider,  gave  supernatural  interpretations 
of  insanity  and  attributed  it  to  demoniacal  inter- 
vention. 

2.     The  Renaissance. 

At  the  close  of  the  sixteenth  century,  under  the 
influence  of  the  impulse  given  by  Alciat,  Wier,  Le- 
loyer,  Montaigne,  physicians  returned  little  by  little 
to  healthier  traditions,  and  Baillon,  Nicolas  Lepois, 
Felix  Plater,  Seunert,  Sylvius  de  le  Boe,  and  Bonet 
endeavored,  not  always  with  success,  to  loosen  the 
yoke  of  prejudice  that  had  so  tenaciously  subjected 
the  foregoing  centuries. 

Paul  Zacchias  (1584-1659),  proto-phj^sician  to 
the  Pope  and  the  states  of  the  church,  in  his  admira- 
ble work  entitled  Questions  Medico- Leg  ales  ^  devoted 
a  very  important  chapter  to  various  states  of  mental 
alienation.  We  find  developed  in  it,  besides  exact 
and  concise  clinical  descriptions,  all  the  medico-legal 
considerations  suggested  by  insanity,  notabl}^  those 
touching  on  civil  capacity,  validity  of  acts,  lucid  in- 
tervals, and  the  moral  and  legal  responsibility  of  the 
insane. 

Mknt.  Mbd,— 2. 


18  filSTORlCAL* 

Sydenham  (1624-1689),  treated  of  insanity  in 
only  an  incidental  manner,  but  he  noted  one  interest- 
ing point ,  that  of  mania  developed  in  consequence 
of  intermittent  fevers. 

Willis  (1622-1675),  whose  works  are  more  im- 
portant and  mark  a  progress  beyond  those  of  his 
predecessors,  gives  good  descriptions  of  mania  and 
melancholia,  which  he  divides  into  partial  and 
general;  of  stupidity,  in  which  he  includes,  as  has 
been  done  since,  imbecility  and  idiocy ;  of  dementia, 
and  even  of  stupor. 

His  descriptions  are  unfortunately  involved  with 
long  discussions  on  the  animal  spirits.  He  ob- 
served the  succession  of  mania  and  melancholia, 
and  in  this  are  found  the  first  traces  of  that 
which  has  been  described  later  as  circular  insanity. 
Willis  also  admits,  though  with  certain  reservations, 
the  intervention  of  demons.  The  rules  of  treatment 
he  gives  are  full  of  good  sense;  unfortunately, 
however,  he  did  not  hesitate  to  advise,  as  frequently 
needful,  rigorous  methods:  '■'■Prima  rudicatio 
curator ia  disciplinarn^  tainas^  vhicida,  cpque  ac 
raedicinani  reqidrit.  Furiosi  nonnunqiiam  citiKS 
per  supplicla  et  critciatvs^  quani  pharmacia  ant 
ntedicanientis  mtrantar. " 

Bonet(1700),  in  his  ISepideretum  insists,  like  Gakm 
and  the  Arabs,  on  the  im})ortance  of  visceral  lesions 
in  insanity,  aiid  reports  at  length  the  lesions  met 
with  iij  autopsies  in  difl'erent  organs. 


THE   RENAISSANCE.  19 

At  this  same  period  there  were  made  some  fortu- 
nate experiments  in  medication,  and  the  cure  of  a 
case  of  relapse  of  mania  by  transfusion  of  blood 
was  reported,  also  some  other  cases  cured  by 
trephining. 

In  the  eighteenth  century  the  study  of  mental 
pathology  entered  definitely  upon  a  new  course. 
There  still  occurred  some  epidemics  of  religious  and 
hysterical  insanity,  perhaps  among  the  persecuted 
Calvinists,  perhaps  at  the  tomb  of  the  deacon  at 
Paris,  but  their  morbid  nature  was  recognized 
and  thej^  were  met  with  treatment,  medical  in  its 
character. 

ViEussENS  (1641-1720),  aside  from  some  neuro- 
ses the  seat  of  which  he  fixed  definitely  in  the  brain, 
only  attempted  to  adapt  his  knowledge  of  mental 
diseases  to  the  humoral  theories  he  supported. 

BoERHAAVE  (1668-1738),  and  his  commentator 
VanSwieten  (1700-1772)  also  subordinated  their  ideas 
of  insanity  to  their  mechanical  theories  and  attrib- 
uted everything  to  the  malignity  of  the  blood  and 
the  black  bile.  They  give  nevertheless  here  and 
there  good  descriptions  of  mania  and  melancholia, 
and  they  point  out,  particularly  in  the  following,  tlie 
principal  physical  characters  of  melancholia  with 
profound  depression,  or,  in  other  words,  of  stupor: 
'''' JPkIsus  lentiorj  frigtis  m.ajus^'  respiratio  lentaj 
circulatio  per  sarKjuinea  vasa  bona  ;  per  lateralia 
mi'iius  bona  ^    Jiinc   hnniQruni   secretiormn,    et   ex- 


20  HISTORICAL. 

rretloriitn   iiiino)\    tardioi\    cratior   exitat<  ^    minoT 
consiinrptio^  parcior  ap^^efitus.'''' 

Soon  howevtT,  under  the  impulsion  of  Ronet, 
Vieussens,and  particularly  of  Morgagni  (J  (382-1771), 
pathological  anatomy  made  rapid  progress  and  there 
was  more  and  more  tendency  to  abandon  tlie  hu- 
moral and  pseudo-chemical  theories  and  to  devote 
more  attention  to  the  examination  of  the  solid 
structures  of  the  body, 

Sauvages  (1706-1767),  anosologist  jt?ar  en'cellence 
made  an  infinite  division  of  the  various  forms  of 
nervous  disorder.  His  eighth  class  made  up  of  the 
reiianius^  or  disorders  that  affect  the  mind,  is  itself 
sub-divided  into  four  orders:  1.  JLjllaHnatiojis 
vertigo,  «limness  of  vision,  diplopia,  tinnitus,  hyjio- 
choudria,  somnambulism.  2.  3forosities,  depraved 
desires  or  affections  (pica,  bulimia,  polydipsia, 
anti])athies,  nostalgia,  panic  terrors,  satyriasis, 
uterine  furor,  tarentism,  hydrophobia).  3.  Delir- 
hiin  (ecstacy,  dementia,  melancholia,  mania,  demono- 
mania).  4.  Ahuornial  aherrations  (loss  of  memory, 
insonniia).  Each  of  these  is  again  split  up  into  more 
oi-  less  numerous  subdivisions. 

Here  and  there  we  find  in  Sauvages  some  good 
descrijjtions,  notably  that  of  anxious  melancholia 
(melancholia  attonita).  l^ut  his  merit  is  in  having 
])rought  together  under  the  name  vesanias  and  in  a 
(complete  classification,  nearly  all  that  was  known  in 
his  day  of  mental  diseases. 

LoRKv  (IT25-1772)  published  some  good  descrip- 


THE    RENAISSANCE.  21 

tions  whicli  were  confused,  however,  by  liis  return  to 
a  doctrine  half  solidist,  lialf  huniornl. 

CuLLEX  (1712-1792),  wlio  forms  tlie  transition 
between  the  Renaissance  and  tlie  modern  ei>ocl), 
rejected  tlie  humoral  theory  entirely  and  insisted 
upon  the  necessity  of  anatonio-})athological  re- 
searches. He  classed  mental  disorders  among  the 
neuroses,  which  form  the  fourth  class  in  liis  work. 
He  described  sijstoiKitlzed  hisanlty^  reniai'king  at  the 
same  time  the  rarity  of  finding  insanity  limited  to  a 
single  subject,  and  admitted  in  his  final  arrangement 
only  two  primary  forms  of  insanity  from  which  he 
derived  all  others  :  mania  and  melancholia.  In  the 
part  devoted  to  treatment  he  recommends  employ- 
ment, baths,  and  bodily  exercises,  and  authorizes 
forcible  methods  of  repression  only  reservedly. 

With  Cullen  we  are  already''  far  removed  from  the 
ignorance  and  obscurity  of  the  middle  ages  and 
mental  science  had  already  realized  an  immense 
advance.  The  condition  of  the  insane  was,  however, 
still  deplorable ;  they  were  scattered  tlii'ough  the  jails, 
in  a  few  asylums,  or  in  miserable  cells.  Very  few 
Avere  in  hospitals,  and  the  so-called  hospitals  that 
contained  these  were  in  realit}^  only  prisons.  Their 
study  was  therefore  as  diflfit-ult  and  inconi})lete  as 
their  lot  \vas  deplorable. 

At  Paris,  after  an  act  of  Parliament  dated  Sep- 
tember 16,  1660,  tlie  insane  passed  first  through  the 
Hotel  Dieu,  where  two  wards  were  reserved  for 
them.     The  ward  St.  Louis,  devoted  to  men,  con 


22  HISTORICAL. 

tained  ten  beds  for  four  each  and  two  small  beds. 
St.  Martin  ward  for  females  contained  six  large  beds 
and  six  small  ones.  Some  places  in  these  wards 
were  reserved  for  cases  of  hydrophobia,  then  the 
treatment  employed  consisted  invariably  in  douches, 
cold  baths  and  repeated  bleedings,  with  the  in- 
ternal use  of  hellebore,  purgatives  and  antispas- 
modics. 

If  after  several  weeks  the  patients  remained  un- 
cured,  and  we  can  see  readily  how  such  a  course 
could  do  little  to  restore  the  reason,  they  were  con- 
sidered incurable  and  distributed  either  to  the  Petits 
Maisons,  which  afterward  became  the  hospital  of  the 
Menages,  the  Salpetriere,  or  the  Bicetre. 

There  ill-nourished,  covered  with  rags,  loaded 
with  chains  and  collars  of  iron,  confined  in  infected 
cells  intended  for  criminals,  bedded  on  rotten  straw, 
breathing  a  mephitic  atmosphere,  they  dragged  out 
a  miserable  existence,  exposed  to  the  view  of  the 
public  who,  being  admitted  on  holidays  on  the  pay- 
ment of  a  fee,  repaired  to  view  the  sight  and  to 
tease  them  like  wild  animals  through  the  bars  of 
their  cages. 

It  was  at  this  time^that  Pinel  appeared  and 
brought  about  the  memorable  reform  of  1793, 
w^hich  changed  completely  the  lot  of  the  insane  and 
inaugurated  a  new  era  in  the  history  of  mental 
medicine. 


MODERN    EPOCH.  23 

FOURTH  EPOCH. 

{Modern  epoch). 

Philip  Pinel,  born  in  1755  at  St.  Paul,  near 
Lavaur  (Tarn),  and  graduated  at  Toulouse,  became 
physician  to  the  insane  at  the  Bicetre  in  1703. 

We  have  seen  in  what  condition  he  found  the 
insane.  Thanks  to  his  earnest  protests,  which  he 
made  to  be  heard,  he  succeeded  in  removing  their 
chains,  and  provoked  also  a  general  movement  in 
favor  of  these  unfortunates.  For  bad  treatment, 
brutal  violence,  blows  and  chains,  he  substituted 
wisely  combined  methods  of  repression,  he  praised 
the  effects  of  firmness  combined  with  mildness  and 
patience,  and  finally  laid  down  the  first  bases  of 
moral  treatment.  He  demonstrated  the  necessity  of 
creating  special  establishments  for  the  insane, 
pointed  out  the  principles  that  ought  to  govern  their 
construction,  their  organization  and  their  manage- 
ment, the  need  of  the  separation  of  the  patients 
in  distinct  quarters  according  to  the  nature  of  their 
mental  disease ;  in  a  word  drew  up  the  first  rules  for 
the  hospitalization  of  the  insane  and  made  to  be  un- 
derstood the  role  of  the  physician  in  the  observation, 
and  medical  and  material  direction  of  his  patients. 
He  was  aided  in  the  practical  details  of  his  reform 
by  the  overseer  of  the  Salpetriere,  Pussin,  his  modest 
collaborator,  whose  part  w^as  not  a  less  active  one 
and  whom  Pinel  himself  has  associated,  in  a  certain 
measure,  with  the  honor  of  his  glorious  innovation. 


24  HISTORICAL. 

Such  is,  in  substance,  the  story  of  the  reform  innti- 
tuted  by  Pinel.  One  man  by  his  generous  initiative 
and  his  persistent  will,  realized  that  whieli  many 
centuries  had  vainly  sought  :  the  rehabilitation  of 
the  lunatic  and  his  elevation  to  the  dignity  of  a 
sufferer  from  disease.  It  is  needful,  however,  to  be 
just,  to  recognize  that  this  undertaking  came  in  its 
own  time  and  that  it  was,  so  to  speak,  one  of 
the  manifestations  of  that  immense  philanthropic 
tendency  that  enwrapt  all  the  great  spirits  of  that 
epoch. 

Moreover,  the  undertaking  of  Pinel  was  not  an 
isolated  one.  At  the  same  moment  similar  efforts 
were  being  made  at  other  points.  Alread}^  in  Savoy 
Daquin  had  preached  the  same  humanitarian  doctrine 
in  a  more  modest  sphere,  while  Chiaruggi  in  Italy 
published  in  1794  his  treatise  on  Insanity,  General 
and  Special,  in  which  he  stated  the  results  of  the 
ameliorations  obtained  by  him  in  the  asjdum  of  San 
Bonafacio  in  Florence. 

In  England,  a  simple  citizen  of  the  city  of  York, 
William  Tuke,  succeeded  by  his  own  endeavors  in 
doing  still  better.  Witnessing  the  grave  abuses  that 
prevailed  in  the  asylums,  he  influenced  his  co-relig- 
ionists of  the  sect  of  Quakers,  or  the  Society  of 
Friends,  to  found  an  institution  from  which  should 
be  banished  all  severe  physical  measures  and  bad 
treatment.  The  first  stone  of  the  York  Retreat 
was  thus  laid  in  1792,  and  from  its  opening  in 
1796    it   became   the    starting   point  of    the    sue- 


MODEEN    EPOCH.  25 

cessive  improvements  in  the  care  of  the  insane  in 
England.* 

Pinel  was  not  merely  a  reformer,  he  was  also  a  man 
of  science.  Bringing  together  all  the  clinical  aiul  ther- 
apeutical observations  he  had  made  in  regard  to  the 
insane,  he  published  in  the  year  IX,  his  Traitc  de 
la  Ma7iie^  in  which,  after  recalling  the  admirable 
works  of  ancient  writers,  he  stated  his  own  medico- 
philosophical  views  on  mental  alienation.  This  little 
work,  of  w^hich  Cuvier  said  in  the  Institute,  "That 
it  was  not  only  a  medical  work  but  also  a  masterly 
work  on  philosophy  and  even  morals,"  had  a  great 
success,   and  has  since  remained  justly  celebrated. 

Pinel  admits  and  describes  four  species  of  insanity, 
mania^  melancholia.,  dementia  and  idiocy^  in  which 
he  confuses,  like  Willis,  idiocy  and  cretinism,  and 
also  dementia  with  melancholic  stupor. 

At  this  time  there  arose  in  Germany  the  school 
known  as  the  German  psychological  school  which 
started  from  the  spiritualistic  theory  of  Stahl,  accord- 
ing to  which  diseases  are  only  the  perversion  of  the 

*  This  quasi-simultaneousness  of  reforms  in  different 
countries  has,  as  might  have  been  expected,  brought  up 
more  or  less  irritating  disputes  as  to  priority  as  to  the  claims 
of  Daquin,  Cliiaruggi,  Tuke,  and  Pinel.  Such  controversies 
tend  to  diminish  their  glor}--,  and  it  seems  better  to  include 
them  all  alike  in  our  admiration.  In  the  words  of  Hack  Tuke, 
the  worthy  grandson  of  the  English  philanthropist :  ' '  There 
are  enough  evils  in  the  world  for  tlie  few  reformers  who 
appear  from  time  to  time  and  there  is  no  need  of  creating 
between  them  a  state  of  hostile  rivalry." 


26  HISTORICAL. 

moral  tendencies  of  the  soul  produced  by  sin.     Sin, 
therefore,   became  the  principal  cause  of  insanity. 

Langermanu  and  his  pupil  Ideler  were  the  found- 
ers of  this  psychological  school  which  counted  among 
its  adherents  some  illustrious  names,  and  one  of  its 
most  celebrated  representatives  was  Heinroth  (1773- 
1843),  one  of  the  better  disciples  of  Pinel,  who 
held  that  insanity  had  its  source  in  the  absence  of 
morality,  that  its  essential  character  was  the  loss  of 
liberty,  and  its  best  preservative,  attachment  to  the 
truths  of  the  Christian  religion. 

The  opinions  of  the  German  psychologists,  by  their 
exaggeration,  did  not  fail  to  provoke  a  lively  oppo- 
sition. In  Germany,  there  arose  a  new  school,  the 
somatic  school,  which  had  for  its  chiefs,  Nasse, 
Friedreich,  Vering,  Amelung,  Jacobi,  Griesinger, 
and  in  Holland,  Schroeder  van  der  Kolk.  They  all 
protested  against  the  outre  spiritualistic  doctrines  of 
the  psychologists,  and  labored  to  prove  that  insanity 
was  connected  with  physical  lesions,  either  cerebral  or 
visceral.  Like  Galen  and  the  Arabs,  they  accorded 
the  place  of  honor  in  psychiatry  to  the  sympathetic 
insanities. 

In  France,  Esquirol,  born  in  Toulouse  in  1772, 
succeeded  Pinel,  and  his  work  was  as  important  in 
its  influence  on  mental  medicine,  properly  speaking, 
as  that  of  Pinel,  on  the  moral  condition  and  the 
treatment  of  the  insane. 

As  a  philanthropist  and  reformer,  he  continued 
the  work  of  Pinel,  contributed  to  the  construction 


MODERlSr    EPOCH.  27 

and  organization  of  numerous  asylums,  of  which  he 
himself  drew  up  the  plans,  he  improved  more  and 
more  the  condition  of  the  insane ;  and  finally  prepared 
the  way,  by  his  travels  and  writings,  for  the  move- 
ment that  ended  in  the  famous  law  of  1838,  that 
has  been  of  so  great  service,  and  for  which  Faln^t, 
Sr.  and  Ferrus  worked  actively. 

As  a  savant^  Esquirol  left  the  domain  of  pure 
speculation  to  devote  himself  to  observation  and 
clinical  work;  he  drew  up  admirable  tables  of  the 
principal  forms  of  insanity,  to  which  he  added 
monomania,  and  finally  suspected  the  existence  of 
general  paralysis. 

As  a  teacher  he  formed  and  directed  a  magnificent 
constellation  of  students,  so  numerous  and  brilliant 
that  discoveries  accumulated,  and  mental  medi-' 
cine  has  never  made  so  great  a  progress  within  so 
short  a  time. 

At  Charenton,  Bayle,  Delaye,  Georget,  Foville, 
Sr.  and  the  venerable  Calmeil  discovered  and 
described  the  symptoms  and  lesions  of  general 
paralysis. 

At  the  Salpetriere  Trelat  described  reasoning 
mania;  Felix  Voisin  made  a  profound  study  of 
idiocy;  Falret,  Sr.,  combated  the  doctrine  of  mono- 
mania, sent  out  new  general  ideas  on  mental  diseases, 
and,  teacher  in  his  turn,  left  behind  him  pupils  like 
Morel  (the  illustrious  author  of  the  memoirs  on  degen- 
erations, hereditary  insanity,  the  etiological  classifi- 
cation, and  the  introducer  into  France  of  the  system 


28  HISTORICAL. 

of  7ion-rcstr<xint  recommended  in  England  by  Gardi- 
ner Hill  and  Conolly),  Charles  Lasegue,  (the 
describer  of  persecutory  insanity),  and  finally  his 
OAvn  son,  the  eminent  clinicist,  Jules  Falret.  There 
is  also  Leuret,  the  promoter,  perhaps  too  much  the 
subject  of  attack,  of  moral  treatment,  and  M. 
Baillarger,  whose  clinical  discoveries  so  important 
and  well  known  are  too  numerous  to  be  enumerated 
here. 

Still  to  be  mentioned  are  the  names  of  Marc  and 
Fodere,  the  revivers  of  the  legal  medicine  of 
insanity;  Ferrus,  Parchappe,  Marce,  and  others  in 
France  and  elscAvhere  too  numerous  to  mention.  It 
will  suffice  to  cite  only  Conolly,  Guislain  and  Rush, 
whose  influence  in  the  })rogress  and  treatment  of  iu- 
sanitv  in  Enijfliind,  Beliifium  and  America  is  more  or 
less  comparable  to  that  of  Pinel  in  France. 

It  is  necessary  to  stop  here  since  we  encroach  on 
the  present  times  and  some  of  the  names  Ave  might 
cite,  although  already  belonging  to  history,  belong 
to  those  who  are  still  our  masters.  The  future  will 
have  to  judge  as  to  the  progress  made  in  the  study 
of  mental  alienation  since  Pinel  and  Esquirol. 


FIRST  sp:ctiok. 

GENERAL   PATHOLOGY. 


Chapter  ir. 

§  T.     DEFINITIOK 

Distinction  hetween  Insanity  and  Mental 
Alienation. — In  common  medical  language  the 
term  mental  alienation  has  become  synonymous 
with  insanity,  and  these  two  designations  are  usu- 
ally employed  interchangeably .  Scientifically,  never- 
theless, they  have  different  significations,  and  it 
seems  the  more  necessary  to  define  them  accurately 
as  this  difference  is  a  fundamental  one  in  the 
classification  here  adopted. 

Mental  alienation  is  a  generic  term  that  includes 
in  a  general  way  all  the  alterations  of  the  intelli- 
gence from  the  normal,  whether  constitutional  or 
functional,  congenital  or  acquired,  transitory  or 
persistent.  Insanity  has  a  less  extended  significa- 
tion, it  is  only  one  of  the  conditions  of  mental 
alienation,  and  signifies  the  loss  of  reason  strictly 
speaking,  occurring  as  a  disease  in  an  individual 
hitherto  sane.  An  example  will  serve  to  illustrate 
the  distinction.  An  imbecile  is  mentally  alienated, 
inasmuch  as  he  presents  an  evident  defect  of  intel- 


30  GENERAL   PATHOLOGY. 

lect,  an  arrested  development,  but,  however  imbecile 
he  may  be,  he  may  not  be  insane,  and  may  use  nor- 
mally the  restricted  intelligence  he  possesses ;  he  is 
not  a  lunatic.  But  when  this  imbecile,  under  the 
influence  of  any  cause  whatever,  is  attacked  with 
mania  or  melancholia,  we  have  a  new  element  in  his 
case,  his  insanity,  which  is  superimposed  upon  the 
primitive  basis  of  alienation  ;  the  mentallj^  alienated 
individual  has  become  a  lunatic. 

We  may  add,  to  accentuate  the  distinction,  that 
beyond  the  symptoms  it  has  in  common  with  men- 
tal alienation,  insanity  is  nearly  always  unconscious 
of  itself  to  such  a  degree  that  it  may  be  called  a 
misfortune  that  ignores  itself,  and  that  it  has  for  a 
principal  symptom,  if  not  an  absolute  criterion,  the 
loss  of  free  will,  that  is,  of  the  faculty  by  which  the 
sane  man  decides  and  acts  with  knowledge  of  the 
cause,  with  full  freedom  and  reflection.  For  this 
reason,  so  far  as  an  insane  person  is  not  really  dom- 
mated  by  his  morbid  influences,  and  remains  to  a 
certain  degree  master  of  himself,  omni^oi^  nvi^  he  can 
be  considered  as  not  being  a  lunatic  in  the  full  sense 
of  the  word,  there  still  remains  a  last  step  for  him  to 
take,  that  of  the  pathological  subordination  of  his 
ego. 

We  may  call  mental  alienation  therefore,  the  total 
of  tlie  potholoijicol  f'ond!tlo7is  ^i^setithtlly  diorocter- 
ized  by  diHorderH  of  the,  'hitelVKjenre. 

As  to  insanity,  it  has  been  thus  deflned  by  Esquirol : 
"A  cerebral  affection,  ordinarily  chronic,  without 


DEFINITION.  31 

fever,  characterized  by  disorders  of  the  sensibility, 
of  the  intelligence,  and  of  the  will." 

This  definition,  considered  as  the  best  of  all  those 
so  far  offered,  and  they  are  numerous,  is  nevertheless 
very  imperfect,  inasmuch  as  it  may  be  applied  in- 
differently to  all  chronic  cerebral  affections  in  which 
there  is  any  psychic  disorder,  and  in  that  it  does  not 
especially  include  the  distinction  we  have  noted 
between  mental  alienation  and  insanity. 

In  order  to  be  more  precise  and  yet  without  pre- 
tending to  give  an  accurate  definition  of  insanity, 
which  is  in  the  present  state  of  our  knowledge  almost 
an  impossibility,  we  may  say  that  insanity  is  a 
special  disease,  is  a  form  of  alienation  characterized 
by  the  accidental.,  imconscions,  and  more  or  less  2)er- 
manent  disturbance  of  the  reason. 

Synonymy.  Terminology. — Mental  alienation 
has  as  synonyms,  mental  diseases  o\ phrenopathias ; 
insanity,  /)6*2/e/ios/.*?  or  psychopxitlnj;  mental  medi- 
cine, psychiatry  ox  freniatry. 

As  to  the  words  dementia,  monomania,  hallucina- 
tion, delusion,  which  are  often  improperly  used  by 
the  public  as  synonyms  of  insanity,  they  have  each 
a  particular  and  very  different  signification.  Thus 
dementia  is  a  form  of  alienation,  and  it  can  scarcely 
be  made  the  equivalent  of  insanit}'  anywhere  except 
in  judicial  language  where  this  usage  has  prevailed. 
The  same  is  the  case  with  monomania  or  systematized 
insanit}^  which  is  only  a  special  form  of  insanity, 
and  should  not    therefore  be   confounded  with    it. 


32  GENERAL    PATHOLOGY. 

Finally,  as  to  delusion  and  hallucination,  they  are 
merely  the  names  of  two  primary  or  symptomatic 
elements  of  insanity. 

There  remains  a  term,  habitually  misapplied, 
whose  signification  as  established  in  scientilic  lan- 
guage it  is  important  to  state  correctly:  it  is  the 
term  vesania.  We  give  the  name  vesania  to  the 
pure  insanities  in  order  to  distinguish  them  from 
those  connected  with  other  morbid  conditions,  into 
which  they  enter  only  as  symptoms  or  complications. 
For  example,  the  insanity  of  persecution  is  a  type  of 
vesania,  as  it  is  idiopathic  and  forms  by  itself  alone 
the  existing  morbid  condition ;  paralytic  insanity, 
or  the  insanity  that  so  frequently  accompanies 
general  paralysis,  on  the  other  hand,  is  not  a  vesania 
since  it  is  connected  with  a  cerebral  disease,  an 
organic  affection  of  the  nervous  centres.  It  is  need- 
less to  add  that  the  Insane  termed  vesanics  are  in 
consequence  those  aifected  with  pure  insanity  or 
vesania. 

^  II.     ETIOLOGY. 

One  of  the  most  important  parts  of  the  study  of 
mental,  alienation  is  that  of  its  etiology,  and  this  is 
what  mau}^  authors,  notabh^  Morel,  liave  made  the 
basis  of  their  classification. 

The  same  as  with  most  diseases,  there  are,  for 
mental  alienation,  predisposing  and  occasional 
causes.      The  more  important  of    these  have  been 


ETIOLOGY. 


33 


brought  together  by  Marce  in  the    following  syn- 
optical table  : 


Predisposing 
causes. 


General. 


Individual . 


Occasional 
causes. 


Moral. 


Civilization. 
Religious  ideas. 
Political  events. 

Heredity. 

Age. 

Sex. 

Climate. 

Civil  condition. 

Profession. 

Education. 


(  Emotions,  passions,  chagrin. 

■s  Imitation. 

(  Cellular  imprisonment. 


Physical . 


Local 
causes. 


General 
causes. 


Physiolog- 
ical 
causes. 

Specific 
causes. 


r  Acting  directly  on  the 
J      brain. 

I  Acting   at    a    distance 
L     and  sympathetically. 
Anaemia,  cachexia,  sem- 
inal losses,  onanism. 
Diathesis,  dartres^  rheu- 
matism, typhoid  and 
intermittent  fevers. 
Menstruation,  pregnan- 
cy, confinement,  lac- 
tation. 

Intoxications :  lead, 
mercury,  opium,  bel- 
ladonna, poisonous 
solanaciae  haschich. 


A  word  on  each  of  these  causes  in  particular. 


Predisposing  Causes. 

Civilization.  Race. — It  is  generally  recognized 
that  civilization,  by  the  needs  it  creates,  the  habits 
of  luxury  and  pleasure  it  excites,  and  finally  by  the 
struggle  for  existence  that  it  necessitates,  favors  the 
development  of  mental  alienation.  Nevertheless, 
it  is  unpossible  to  say  with  certainty  whether  the 
number  of  the  insane  actually  increases  progressively, 
and,  if  so,  in  what  proportion.  The  census  figures 
have  shown  how  it  has  been  in  France :  in  1835  there 

Mknt.  Med.— 3. 


34  GENERAL    PATHOLOGY. 

Avere  16,538  insane  or  4.96  to  each  10,000  inhab- 
itants; in  1841,  18,367  or  5.37  to  each  10,000; 
1861,  46,357  or  12.95;  in  1866,  90,709  or  23.82; 
in  1876,  83,012  or  22.50  to  the  10,000.  Judging 
only  from  these  results  it  would  appear  that  the 
number  of  the  insane  among  us  has  quintupled  dur- 
ing the  past  thirty-five  years,  but  there  is  in  this 
evidently  an  exaggeration  due  to  the  greater  accuracy 
of  the  recent  censuses.  If  we  take  the  insane,  not 
as  enumerated  in  the  census,  but  the  number  admit- 
ted to  the  hospitals,  we  find  that  the  increase  of  ad- 
missions which  was  annually  12.5  per  cent,  forty 
years  ago,  is  to-day  only  1.70  percent.  The  num- 
ber of  admissions  has  therefore  a  tendency  to  be- 
come stationary.  This  proves,  as  Lunier  states, 
that  the  increase  in  the  number  of  the  insane, 
admitting  that  it  exists,  is,  in  any  event,  less  con- 
siderable than  is  generally  believed. 

Another  interesting  series  of  statistics  is  that  of 
the  insane  of  the  Department  of  the  Seine  from  1801 
to  1883.  It  is  seen  from  these  figures,  that  there 
were  on  January  1,  1801,  945  insane  maintained  at 
public  expense,  while  on  the  31st  of  December, 
1883,  the  number  was  8,907,  or  more  than  six  times 
greater,  while  in  the  same  space  of  time  the  general 
))0|)ulation  of  Paris  has  hardly  more  than  tri})led 
itself,  having  been  600,000  at  the  beginning  of  the 
century  and  2,237,928  by  the  census  of  1881. 

The  statistics  of  other  countries  seem  likewise  to 
afford  contradictory  results. 


ETIOLOGY.  35 

There  is,  nevertheless,  an  interesting  fact  to  be 
noted  relative  to  the  progress  of  insanity  in  the 
black  race.  Solbrig  had  already  observed  that  in 
America  the  free  negroes  of  the  Northern  States  had 
proportionally,  as  it  appeared,  five  times  as  much 
insanity  among  them  as  existed  among  their  colored 
brethren  of  the  South.  According  to  the  more  re- 
cent researches  of  Buchanan,  the  development  of 
insanity  has  increased  rapidly  in  the  colored  race 
since  emancipation. 

In  1850  there  were  enumerated  618  insane  amongst 
the  black  population  of  the  United  States,  in  1860 
their  number  was  706,  or  one  for  every  5,799.  In 
1870  there  were  2,695  colored  lunatics;  in  1880  the 
proportion  was  1  to  1,096,  so  that,  admitting  a 
regular  increase,  this  proportion,  says  the  author, 
will  rise  to  1  to  500  in  1890,  thus  equaling  the  fre- 
quency of  mental  alienation  among  the  Americans 
of  the  white  race. 

If  it  is  impossible,  according  to  these  data,  to 
establish  in  any  positive  manner  the  influence  of 
civilization  upon  the  frequency  of  insanity,  its 
influence  on  the  type  of  alienation,  on  the  other 
hand,  is  much  more  certain.  We  may  say,  in- 
deed, that  the  pure  insanities,  or  vesanias, 
have  existed  from  all  time  and  probably  with- 
out increasing  to  any  considerable  extent. 
Among  them  the  generaliz.ed  insanities,  mania  and 
melancholia,  have  continued  absolutely  identical 
with  their  type  in  ancient  times,  as  anyone  may  con- 


36  GENERAL    PATHOLOGY. 

vince  himself  by  comparing  the  description  given  by 
the  writers  of  antiquit}^  with  the  diseases  as  we  see 
them  at  present.  As  to  the  systematized  insanities, 
while  remaining  fundamentally  the  same,  they  vary  in 
expression  according  to  the  period  and  the  surround- 
ings. The  mental  infirmities  due  to  a  vice  of 
organization  (idiocy,  cretinism)  seem  to  diminish 
with  civilization,  mainly  on  account  of  the  ameliora- 
tion in  the  material  life  that  results  from  it. 
Alcoholism,  alcoholic  insanity,  and  in  a  general  way 
all  the  toxic  cerebropathies  increase  very  notabl}'^, 
especially  in  certain  countries  and  in  the  great 
centres.  Finally,  general  paralysis,  absolutely  un- 
known prior  to  the  present  century,  whether  it 
existed  then  or  not,  is  becoming  more  and  more 
frequent,  especially  in  the  female  sex. 

It  would  be  interesting,  aside  from  the  effects  of 
civilization  in  general,  to  indicate  the  comparative 
liability  of  the  various  races  to  mental  alienation  and 
to  each  of  its  forms.  Unfortunately  we  lack  reliable 
statistics  on  this  point.  It  appears,  however,  from 
certain  memoirs,  particularly  an  interesting  publica- 
tion in  1888,  by  Drs.  Bannister  and  Ludwig  Hektoen 
of  Illinois,  in  regard  to  a  considerable  number  of 
patients  treated  in  their  asylums,  that  the  Jewish 
race  stands  at  the  head,  especially  as  regards  general 
paralysis,  mania  and  melancholia.  The  African, 
Anglo-Saxon  and  Anglo-American,  Latin,  Teutonic, 
Celtic,  and  Scandinavian  races  follow  after  with 
figures  more  or  less  variable.     But,  I  repeat,  these 


ETIOLOGY.  37 

results,  being  purely  local,  cannot  be  taken  as  repre- 
senting the  real  state  of  affairs  in  its  totalitj^. 

Religious  Ideas. — The  influence  of  religious 
ideas  in  the  production  of  insanity  varies  according 
to  the  epoch,  the  country  and  the  surroundings. 
Very  active  in  France  at  the  times  of  the  religious 
wars  of  the  reformation,  and  of  ardent  polemics,  it 
has  become  much  less  at  the  present  day,  though 
still  somewhat  apparent.  On  the  other  hand,  it  still 
plays  a  large  part  in  countries  where  the  religious 
sentiments  occupy  one  of  the  chief  places  in  the 
public  mind.  Nothing  is  more  communicable  than 
ideas  of  religion  and  mysticism ;  for  this  reason  the 
insanitj^  they  engender  takes  most  frequently  an 
epidemic  type. 

Religious  ideas  give  rise  to  insanity  principally  in 
those  who  offer  the  easiest  prey,  that  is,  in  a  general 
way,  the  weak-minded,  children,  females,  nervous 
persons,  and  especially  members  of  religious  orders, 
male  and  female,  and  more  particularly  those  of  a 
mystic  and  contemplative  character. 

The}^  have  also  a  very  manifest  effect  at  certain 
stages  of  life,  especially  the  great  epochs  of  sexual 
life:  puberty  and  the  menopause.  It  is  known, 
moreover,  that  direct  relations  exist  between  mystic 
an<l  erotic  ideas,  and  that  very  often  these  two  kinds 
of  conceptions  are  found  associated  together  in 
insanity. 

Political  Events.  Wars. — The  importance  of 
political  commotions,  revolutions  and  wars  as  a  cause 


38  GENERAL   PATHOLOGY. 

of  mental  alienation  has  always  been  overestimated. 
The  truth  is  that  these  great  events  have  for  a 
special  effect  that  tliey  call  out  and  bring  before  the 
public  a  certain  number  of  lunatics  who  in  peaceful 
times  would  have  ]>assed  unnoticed,  and  also  that 
they  communicate  a  special  coloring  to  the  delusive 
ideas  of  the  time.  Great  scientific  or  social  move- 
ments that  occur  in  society  act  in  the  same  way. 
Great  disco\'eries,  or  inventions,  and  powerful  asso- 
ciations hardly  indeed  affect  the  insane  except  to 
color  tlieir  delusions  and  impress  upon  them  a  special 
physiognomy. 

Heredity. — Heredity,  which  is,  without  contra- 
diction, the  most  powerful  and  important  of  all  the 
causes  of  insanity,  merits  a  few  words. 

Definition. — By  heredity  is  understood  in  mental 
pathology  an  original 2wedis2x>sition  to  mental  alien- 
ation transmitted  to  cltihlren  fc<>ni  their  jxirejits. 

Nature.  Frequency. — Tlie  source  of  this  predis- 
position may  be  not  merely  mental  alienation  in  the 
ancestors,  but  other  related  diseases,  eccentricit}'^, 
neuroses,  alcoholism,  certain  diatheses,  consan- 
guinity, &c.  IJecause  of  not  acc€q)ting  heredity  in  its 
widest  and  ti'ucst  signification  and  restricting  it 
more  or  less  to  (rases  of  direct  transmission  of  in- 
sanity itself,  there  was  some  disagreement  as  to  the 
exact  fre(juency  of  this  cause  of  alicMiation.  In  re- 
ality, we  may  admit  with  Marce,  that  we  find  some 
antecedent  in  nine-tenths  of  all  the  cases. 


ETIOLOGY.  39 

Characters.  Forms.  Varieties. — Heredity  is  most 
frequently  from  the  parents,  that  is,  it  is  immediate. 
It  may  be  on  the  side  of  both  father  and  mother,  and 
in  that  case,  it  is  called  double.,  or  from  convergent 
factors.  Generally,  it  is  from  one  parent,  either 
father  or  mother,  and  then  it  is  simple  heredity., 
either  paternal  or  maternal.  According  to  Esquirol 
the  latter  is  the  more  serious  of  the  two.  It  is  also 
three  times  more  common  than  paternal  heredity, 
according  to  M.  Baillarger. 

The  heredity  may  be  traced  from  the  grand- 
parents, having  passed  hy  the  immediate  ancestors. 
It  is  then  mediate  heredity.  It  may  also  have  existed 
for  many  prior  generations  and  in  that  case  it  is 
called  citmidative. 

Heredity  is  either  direct  or  collateral  according  as 
it  is  observed  in  parents  or  grandparents  or  in 
collateral  branches  of  the  family. 

Hereditary  insanity  may  appear  in  children  at  the 
same  time  that  it  appeared  in  the  parent,  and  it  is 
then  called  homoehronoiis.  It  may  also  appear  in 
children  a  longer  or  shorter  time  before  it  is  seen  in 
the  parent.  It  may  then  be  called  anticipatory  as 
regards  the  parental  disease,  which  has  so  far 
remained  latent. 

The  hereditary  taint  may  reveal  itself  in  the 
children  hj  a  mental  disorder  identical  with  that  of 
the  parent.  This  occurs  in  cases  of  suicidal  impulse 
and  sometimes  also  in  certain  forms  of  alienation, 
such,  for  example,  as  circular  insanity.      It  is  then 


40  GENERAL   PATHOLOGY. 

shnilar  or  homologous.  It  is  dissimilar  or  trans- 
formed., on  the  other  Land,  when  it  is  modified  in 
passing  from  one  generation  to  another.  Tliis  is 
generally  the  case  and  it  maj^  become  more  and 
more  intensified  and  end  in  the  degeneration  of  the 
race,  ^,  e. ,  be  progressive;  or  it  may,  on  tlie  contrary, 
become  attenuated  by  a  series  of  fortunate  crossings, 
and  finally  disappear  entirely, — it  is  then  regressive. 

The  hereditary  taint  does  not  affect  all  the  mem- 
bers of  the  same  family  indiscriminately,-  a  certain 
number  may  escape  its  influence.  It  is  even  the  rule, 
according  to  Morel,  to  see  in  insane  families  dis- 
similar types.  This  dissimilarit}"  may  sometimes 
reach  a  point  that  we  find  in  these  families,  together 
with  insane  and  degenerated  individuals,  men  of 
talent  and  even  of  genius.  (Relation  of  genius  with 
insanity.)  In  some  instances,  two  or  more  brothers 
or  sisters,  together  or  separated,  are  affected  sim- 
ultaneously and  in  an  identical  manner,  [Folie  d  deux., 
Folie  gemellaire) . 

As  a  rule,  the  children  most  liable  to  the  heredi- 
tary taint  are  those  whose  birth  was  nearest  in  time 
to  the  attack  of  insanity  of  the  parents.  This  is 
notably  the  case  witli  children  born  of  a  motlicr  in 
an  attack  of  puerperal  mania,  or  begotten  by  a 
father  in  a  state  of  intoxication. 

Heredity,  in  mental  alienation,  seems  to  affect 
several  types,  the  principal  ones  of  wliicli  are: 
(1)  vesanic  lieredity,  or  tlie  heredity  of  pure  insan- 
ity or  vesania ;  (2)  cerebral  or  congestive  heredity, 


ETIOLOGY.  41 

^.  e.,  the  heredity  of  cerebral  affections  and  general 
paralysis;  (3)  neurotic  heredity,  or  that  of  the 
neuroses. 

Age. — Tlie  frequency  of  mental  alienation  is  most 
marked  in  tlie  middle  period  of  life;  before  and 
after  that  it  gradually  diminishes  according  as  we 
approach  the  two  extremes  of  infanc}^  and  old  age. 
The  principal  important  periods  of  life,  such  as 
pubert}'^  and  the  climacteric,  are  the  signal  for  a  recru- 
descence of  the  frequency  of  insanit}^ 

Sex. — In  general  statistics  of  mental  alienation  the 
male  sex  figures  more  largely  than  the  female :  the 
proportion  is  114  to  129  males  to  each  100  females. 
If  the  cases  of  idiocy  and  cretinism,  most  frequent 
among  males,  are  excluded,  a  certain  equilibrium  is 
re-established,  and  if  we  go  further  and  take  out  all 
the  cases  of  general  paralysis  and  alcoholism,  we  find 
that  pure  insanity  is  more  frequent  in  the  female  than 
in  the  male.  It  is  necessary  to  add  that  certain 
mental  disorders,  like  those  connected  with  preg- 
nane}'', are  peculiar  to  the  female,  and  that  some 
others,  common  to  both  sexes,  have  special  char- 
acters in  women. 

Climate.  Seasons.  Lunar  Phases. — It  is 
scarcely  possible  to  state  the  comparative  influence 
of  different  climates  on  the  production  of  insanity,  be- 
cause of  the  multiplicity,  and  especially  the  diversity, 
of  the  superadded  causes.  The  one  fact  that  appears 
to  be  settled  is  the  greater  frequency  of  alienation 


42  GENERAL    PATHOLOGY. 

at  certain  seasons,  especially  in  the  semester  of  March 
to  September.  Examining,  from  this  point  of  view, 
the  statistics  of  32,000  patients  passed  through  the 
Inlirmerie  du  Depot  at  Paris,  Planes  found  that  the 
number  of  insane  constantly  increased  from  January 
to  June.  After  June  a  decrease  Avas  observed  with 
almost  or  quite  the  same  regularity,  and  was  followed 
by  a  considerable  increase  in  October.  Legoyt  and 
Ogle  ol)tained  similar  results.  The  latter,  among 
42, 030  suicides  in  England  and  Wales,  found  the 
minimum  in  December  and  the  maximum  in  June. 
The  order  of  importance  of  the  trimesters  is,  accord- 
ing to  Planes :  the  second,  the  third,  the  first,  the 
fourth.  The  maximum  does  not  correspond,  as  is 
generally  believed,  with  the  heats  of  summer,  but 
with  the  effervescence  of  spring. 

The  ancients  and,  in  more  recent  times,  Esquirol, 
attached  a  certain  importance  to  the  influence  of  the 
seasons,  not  only  on  the  development  but  also  on  the 
course  of  insanity:  this  or  that  attack  should  pass  off 
at  such  a  time;  if  is  was  passed  without  recovery  the 
prognosis  became  more  serious.  As  to  the  influence 
of  the  lunar  jjhases,  fomierly  regarded  as  so  import- 
ant that  in  some  countries  it  gave  a  name  to  the  in- 
sane individual  (lunatic),  it  is  hardly  admitted  at  the 
])resent  time.  It  aj)])ears,  nevertheless,  that  it  may 
have  some  effect  on  the  return  of  the  attack  in  inter- 
mittent insanity,  and  es])ecially  in  circular  insanity. 

Civil  Condition. — All  statistics  are  in  accord  in 
recognizing  that  insanity  is  more  common  amongst 


ETIOLOGY.  43 

celibates  than  amongst  married  individnals.  Tlie 
fact  is  usually  explained  by  sayino-  that  the  condition 
of  celibacy  favors  irregularities  of  living  and  deprives 
the  individual  of  moral  support.  It  would  perhaps 
l)e  more  correct  to  sa}^  that  the  same  cause  that  pro- 
duced insanity  was  also  responsible  for  the  celibacy. 
It  appears,  in  fact,  that  those  predisposed  to  insanit}" 
are,  by  reason  of  their  special  temperament,  often  led 
to  put  off  marriage  and  lead  a  solitary  and  egoistic 
existence.  It  is  also  to  be  remarked  here  that  by  a 
sort  of  attraction,  frequently  unconscious,  the  predis- 
posed to  insanity  have  a  tendency  to  seek  out  alliances 
amongst  themselves.  Finally  it  is  proper  to  say  that 
the  condition  of  widowhood  has  a  positive  influence 
on  the  development  of  insanit}^ 

Professions, — In  all  countries,  but  in  England 
especially,  soldiers  and  sailors  occupy  the  first  place,  as 
regards  numbers,  in  the  statistics  of  mental  alienation. 
General  paralysis  is  especially  frequent  amongst 
them.  Certain  forms  of  epidemic  insanity,  such  as 
nostalgia,  suicidal  impulse,  are  not  infrequently  met 
with  in  the  ranks  of  the  army. 

In  the  liberal  professions,  law^^ers,  ecclesiastics, 
physicians,  writers,  and  artists  appear  to  pay  tlie 
largest  tribute  to  insanity.  According  to  a  rather  wide- 
spread notion,  alienists  and  all  others  who  live  with 
the  insane  will  have  a  tendenc}^  to  lose  their  reason, 
from  the  effect  of  contiguit}^  This  is,  it  is  needless 
to  say,  a  po^jular  error,  since  contact  with  the  in- 


44  GENERAL    PATHOLOGY. 

sane  can  have  no  effect  except  upon  those  ah*eady 
predisposed. 

In  the  manual  j^rofessions  those  most  exposed  to 
become  insane  are  such  as  work  in  toxic  or  dangerous 
substances,  and  in  particular  alcohol,  and  those  who 
are  exposed  to  intense  heat,  sucli  as  firemen,  engineers, 
cooks,  employes  in  manufactories,  etc. 

Education. — A  vicious  education,  too  rigid  or 
too  lax,  as  well  as  too  rapid  and  precocious,  may 
give  rise  in  the  child  to  tendencies  to  insanity,  or, 
what  is  more  common,  develop  tendencies  alread}^ 
existing.  The  education  therefore  of  those  predis- 
posed to  insanit}-^  and  the  cliildren  of  the  insane 
require  special  care  and  regulation. 

Occasional  Causes. 

1.     Moral  Causes. 

Passions.  Emotions.  Imitation. — Tlie  action 
of  occasional  causes,  moral  aud  ph^^sical,  on  the 
development  of  insanity  is  undeniable,  but  it  ought 
not  to  be  overestimated,  and  it  is  well  to  know  that 
without  an  already  existing  predisposition,  without 
the  conjunction  of  the  seed  and  the  soil,  in  tbe  words 
of  M.  Ball,  this  action  would  be  inefficacious. 

Among  the  occasional  causes,  the  moral  causes 
take  tlie  first  place,  and  among  these  the  })assions 
and  the  emotions,  which  really  include  all.  The 
depressive   emotions   have   a   much   more  powerful 


ETIOLOGT.  45 

action  than  their  opposites.  Those  that  have  the 
most  effect  are  the  violent  emotions,  terror,  the  moral 
shock  due  to  criminal  assault,  the  impression  made  by 
the  hrst  conjugal  relations  (post-connubial  insanity), 
the  loss  of  a  beloved  wife,  disappointment  in  love, 
the  mental  preoccupations  due  to  poverty,  strange 
mystic  emotions,  but,  before  all,  domestic  troubles 
and  business  reverses.  However  sudden  and  un- 
expected the  action  of  these  causes  may  be,  it  is 
very  rarely  that  the  insanity  manifests  itself  im- 
mediately, as  is  wrongly  supposed  by  the  public,  at 
least  in  its  full  intensity. 

As  to  imitation,  it  may  have  a  certain  action  on 
weak  mental  organizations  always  ready  for  any 
occasional  cause.  This  action  may  affect  at  the  same 
time  a  large  number,  as  in  the  famous  epidemics  of 
insanity  in  the  middle  ages,  and,  as  happens  at 
present,  from  the  influence  of  the  recitals  of  certain 
crimes  and  suicides  in  the  press;  at  other  times  it 
acts  within  navrow  limits,  the  intimate  relations  of 
the  family  and  the  home  {folie  d  deux,  suicide  d 
deux) . 

Solitary  Confinement. — As  has  been  said  by 
Lelut,  the  greater  frequence  of  insanity  in  a  crim- 
inal and  convict  population  is  a  fact  as  well  known 
to  science  as  to  the  law.  But  if  it  be  correct  to  say 
that  imprisonment,  and  solitary  confinement  more 
particularly,  have  a  certain  influence  on  the  mental 
condition  of  the  prisoners,  it  is  necessary  to  recog- 


46  GENERAL    PATHOLOGY. 

nize  also  the  fact  that  the  true  cause  of  prison 
insanity  is  not  in  the  prison  but  in  the  prisoners,  who 
are  often  hmatics  or  on  the  point  of  becoming  such 
at  the  time  of  their  condemnation,  and  wlio,  more- 
over, are  frequently  recruited  among  the  semi- 
imbecile,  the  perverse  and  ill-balanced.  M.  Semal, 
of  Mons,  who  has  made  a  minute  inquiry  in  regard 
to  005,000  accused  and  convicted  persons  in  Belgium, 
(Congress  of  Paris,  1880),  has  likewise  shown  that 
individual  predispositions,  heredity  in  particular,  con- 
stitute the  principal  factors  of  insanity  among 
prisoners.  As  to  the  occasional  causes,  they  rank 
in  the  following  order:  1,  Insufficient  food;  2, 
solitary  confinement ;  3,  onanism;  4,  loss  of  freedom, 
sedentary  life;  5,  various  moral  influences.  The 
atmosphere  of  the  prison  has,  he  claims,  an  evident 
action  on  the  evolution,  and  more  particularly  on 
the  form  of  the  mental  disorder.  The  frequency  of 
hallucinations  of  hearing,  notably  in  those  confined 
by  themselves,  is  an  undeniable  proof  of  this. 

2.     Physical  Causes. 

a.  — Local  Causes. 

1.  Direct. — Injuries  of  the  head  may  be  the 
starting  point  of  insanity,  and  even,  it  is  said,  of 
general  ])aralysis.  Tlie  same  is  true  of  diseases  of  the 
bones  of  tlie  cranium,  cerebral  tumors,  erysipelas  of  the 
scalp,  and  es})ecially  inflammation  of  the  middle  or 
inner  ear.     Insolation  also  calls  for  special  mention, 


ETIOLOGY.  47 

among  these  causes,  as    in    some   countries  it  is   a 
frequent  source  of  insanity. 

2.  Sympathetic. — Some  local  2:)hysical  causes, 
produce  insanity  by  an  action  at  a  distance  and  by 
contreeoup  instead  of  directly,  whence  the  terms 
sympathetic  insanity  or  insanity  by  consensus  given 
to  the  disorder  they  thus  produce.  The  principal 
ones  of  these  causes  are,  the  physiological  and 
pathological  processes  of  the  genital  apparatus 
(puberty,  menstruation,  menopause,  pregnancy, 
affections  of  the  genitals),  disease  of  the  abdominal 
viscera,  the  presence  of  worms  in  the  intestines,  etc. 
The  mechanism  of  the  production  of  the  insainty  in 
these  cases  seems  often  to  be  an  auto-intoxication, 
through  excessive  production  or  retention  of  poisons 
of  the  system. 

h. — General  Causes. 

Anjemia.  Cachexia.  Diatheses.  Fevers. — 
Chlorosis  and  anaemia,  by  debilitating  the  organism 
and  the  brain,  favor  the  development  of  insanity. 
Excessive  seminal  losses  and  onanism  seem  to  act  in 
the  same  way.  As  to  the  diatheses,  such  as  the 
arthritic,  dartrous,  syphilitic,  etc.,  they  also  have  an 
action  in  the  development  of  insanity,  cither  as  they 
directly  give  rise  to  lesions  in  the  brain,  or  as  the 
insanity  supervenes  during  one  of  their  acute  phases, 
or  after  the  disappearance  of  one  of  their  manifesta- 
tions, cutaneous  or  otherwise,  as  if  by  a"'  sort  of 
metastasis,  or  as  the  toxic  effect  of  a  nutrition 
retardant. 


48  GENERAL    PATHOLOGY. 

Among  the  fevers,  tj^phoid  and  intermittent  fevers 
are  more  or  less  important  producers  of  insanity. 
This  latter  has  also  been  observed  to  follow  cholera 
and  la  grippe.  It  is  less  rare  to  see  it  occur,  either 
during  the  course  or  the  decline  of  certain  acute 
affections  such  as  pneumonia,  variola,  erysipelas,  etc. 

c.  — Physiological  Causes. 

Puberty,  menstruation,  the  climacteric,  pregnancy, 
toonfiuement,  lactation,  etc.,  are  very  often  accom- 
panied with  intellectual  disturbances  which,  in  some 
cases,  may  end  in  insanity.  This  is  usually  ranked 
among  the  sympathetic  insanities. 

d. — Specific  Causes. 

A  certain  number  of  toxic  substances  that  have  a 
decided  action  on  the  nervous  system  may  give  rise 
to  insanity.  The  more  active  of  these  substances,  at 
least  in  Eurojje,  are  alcohol,  the  ravages  of  Avhich  are 
fearful  in  France,  in  the  large  cities  of  the  north, 
lead,  opium,  tobacco,  haschisch,  and  lastly  morphine 
and  cocaine  Avhich  for  some  years  have  been  the 
fashionable  poisons,  especially  amongst  nervous 
women,  ataxics,  and  ill  balanced  individuals. 

g  III.     PROGRESS. 

Distinction  of  Insanity  into  Acute  and 
Ohronic. — Mental  alienation,  though  a  disorder  of 
,slow  evolution  and  usually  chronic,  may  present  it- 


PROGRESS.  49 

self  vinder  an  acute  or  under  a  chronic  form,  properly 
so-called. 

The  mental  alienations  that  we  shall  studj^  later  on 
under  the  name  of  constitutional  alienations,  are 
durable  and  permanent  conditions.  As  to  the  insani- 
ties or  functional  alienations,  only  one  class,  that  of 
the  generalized  insanities,  can  take  on  an  acute  form ; 
the  second  class,  that  of  the  systematized  insanities,  is 
essentialh^  chronic  from  the  first.  The  distinction 
of  the  insanities  into  acute  and  chronic  is  the  more 
important  since  the  former  only  are  curable ;  whence 
it  follows,  a  jy'^^ori^  that  only  the  generalized  in- 
sanities are  susceptible  of  bemg  cured. 

Beginning  of  Insanity. — Chronic  insanitj^  always 
begins  in  a  slow  and  progressive  manner.  As  to 
acute  insanity,  while  it  may  in  certain  exceptional 
cases  break  out  suddenly,  it  much  more  commonl}^ 
appears  by  a  series  of  gradual  transitions.  What- 
ever may  be  its  progress  and  final  form,  insanity  is 
generally  preceded  by  a  period  of  malaise  or  depress- 
ion, more  or  less  marked,  which  sometimes  consti- 
tutes a  veritable  stage  of  melancholia. 

Passage  to  the  Chronic  Condition. — The 
acute  insanities  may  pass,  after  a  time,  into  the 
clironic  condition;  dating  from  that  instant  they 
cease  to  be  curable.  The  precise  moment  when  an 
attack  of  mania  or  melancholia  becomes  chronic  is 
very  hard  to  determine,  nevertheless,  as  a  practical 
matter,  it  is  of  the  first  importance.     The  absence 

Mbnt.  Med.— 4. 


50  GENERAL    PATHOLOGY. 

of  remissions  of  the  disease,  the  persistence  and 
uniformity  of  the  dehisive  ideas,  the  change  from 
acute  excitement  and  melancholia  into  a  sub-acute 
condition,  certain  earthy  or  bronze  colorations  of  the 
skin,  but  more  than  all  other  signs,  the  return  of 
strength  and  increase  of  flesh,  which  contrasts  with 
the  lack  of  improvement  of  the  mental  functions, 
and  seems  to  indicate  that  the  body,  ceasing  to  be 
one  with  the  mind,  has  now  begun  a  life  apait  and 
independent,  such  are  the  indications  that  permit  us 
generall}^  to  decide  almost  to  a  certainty. 

Different  Types  of  Evolution  of  Insanity. — 
Insanity  may  be  continuous,  as  seen  mostly  in  the 
acute  and  curable  attacks,  or  remittent  or  intermittent, 
which  is  the  usual  type  in  the  chronic,  hereditary 
and  curable  forms.  The  remittent  type  is  the  most 
frequent  one. 

Remission. — A  remission  is  an  attenuation  of  the 
symptoms  of  the  disease.  It  may  occur  either  in 
the  course  of  an  attack,  Avhich  takes  on  a  special 
character  from  this  fact,  or  at  the  end  of  an  attack, 
as  a  signal  of  approaching  recovery,  or  yet  between 
two  attacks  which  it  connects  by  a  sort  of  j^athologi- 
cal  transition.  Kemissions  may  be  more  or  less  pro- 
nounced, but  to  whatever  degree  they  attain,  they 
are  only  attenuation  and  not  absolute  cessation  of 
the  symptoms,  wliich  continue  to  exist  to  the  same 
extent.  It  is  this  feature  that  differentiates  remis- 
sions from  lucid  intervals  or  recovery. 


DURATIOlsr.  51 

Intermissions. — An  intermission  is  a  complete 
return  to  the  normal  condition  occurring  between 
two  attacks  of  insanity.  Such  insanities  character- 
ized by  intermissions  with  regular  returns  of  the 
disorder  are  called  intermittent.  Of  this  kind  are 
intermittent  mania,  certain  varieties  of  double  form 
insanity,  etc. 

Lucid  Intervals. — A  lucid  interval  is  a  tem- 
porary and  complete  suspension  of  the  symptoms  of 
insanity.  It  differs  from  a  remission  in  tliat  it  is 
not  a  simple  attenuation  but  a  complete  disappear- 
ance of  the  symptoms  and  from  an  intermission  in 
that  it  merely  interrupts,  like  a  momentary  gleam, 
the  course  of  an  attack. 

All  these  peculiarities  of  the  course  of  mental 
disorders,  and  which  have  been  well  elucidated  by 
M.  Doutrebente  in  a  special  memoir,  have  a  consider- 
able importance  in  a  medico-legal  point  of  view. 

§  IV.     DURATION. 

Duration  of  Subacute  Insanity,  Transitory 
Insanity. — Insanity  is  a  disease  the  evolution  of 
which  is  rarely  rapid.  It  is  only  in  a  few  particular 
l*orms  like  acute  delirium  and  transitory  insanitj^  that 
its  duration  is  limited  to  but  a  few  days.  Generally 
it  takes  a  more  or  less  considerable  period  of  time, 
even  in  acute  cases. 

Duration  of  Acute  Insanity. — It  is  verj^  rarety 
that  a  recent  acute  case  of  mania  lasts  less  than  one 


52  GENERAL    PATHOLOGY. 

month ;  :"in<l  the  same  is  the  case  with  acute  melan- 
cholia. Ordinarily,  the  recover}^  takes  place,  if  it 
occurs  at  all,  between  the  second  and  the  eleventh 
month. 

Duration  of  Chronic  Insanity. — The  chronic 
and  incurable  forms  of  insanity  are  usually  of  very 
long  duration.  Certain  manias,  and,  more  especialh% 
systematized  insanities  are,  so  to  speak,  interminable. 
It  is  not  uncommon  to  find,  in  asylums,  old  cases  of 
vesania,  constantly  deluded,  living  thirty  or  forty 
years,  and  even  more. 

ii  V.     TERMINATIONS.— COMPLICATIONS. 

The  three  possible  terminations  of  mental  alienation 
are  recovery,  incurabilitj^,  and  death. 

Recovery. — Recovery,  which  only  occurs  in 
acute  cases,  ma}^  take  place  in  several  different  waj^s : 
(1)  suddenly  or  instantaneously,  which  is  not  tlie 
rule,  and  is  most  frequent  in  intermittent  insanities 
and  hereditary  forms;  (2)  by  a  series  of  gradual  os- 
cillations terminating  in  the  return  of  reason;  (3)  b}^ 
a  gradual  disappearance  or  diminution  of  the  symp- 
toms. Tliese  last  two  modes  are  rather  frequent,  and 
generall}''  satisfactoiy. 

Incurakility. — Incurability  may  exist  from  the 
first,  as  in  constitutional  alienations,  cliionic  geni;ral- 
ized  insanity,  and  systematized  insanity,  or  secondary 


TERMIlSrATIONS.      COMPLICATIONS.  53 

or  consecutive  to  the  passage  of  acute  insanity  into 
the  chronic  state,  as  has  l)een  ah'early  indicated. 

Death. — Death  is  sometimes  the  consequence  of 
the  mental  disease  itself,  hut  tliis  rarely  occurs  except 
in  some  superacute  insanities  like  acute  delirium,  and 
in  some  other  disorders,  like  general  paralysis.  More 
frequently  it  is  the  result  of  a  complication  or  in- 
cidental disease. 

Complications.  Incidental  Disorders.  Crlses. 
— Generally  speaking,  the  mortality  of  the  insane  is 
higher  than  that  of  the  population  as  a  whole.  An 
equilibrium  is,  however,  more  nearly  re-established  if 
we  deduct  from  the  number  of  the  insane,  the  general 
])aralytics,  inevitably  doomed  to  die  within  a  short 
period.  One  very  curious  fact  is  the  immunity, 
sometimes  very  marked,  that  is  enjoyed  by  the 
chronic  insane  to  atmospheric  influences  and  acci- 
dental endemic  or  epidemic  diseases,  and  this  in  spite 
of  their  frequent  unconscious  imjunidences.  Another 
peculiarity,  equally  striking,  is  the  good  effect  that 
intercurrent  disorders  sometimes  exert  on  the  progress 
of  the  insanity,  acting  in  this  as  a  sort  of  derivation. 
This  action,  to  which  attention  was  called  by 
Esquirol,  goes  by  the  name  of  crisis,  and  he  goes  so 
far  as  to  say  that  there  can  be  no  effective  cure  of 
insanity  but  in  this  wa}^  Finally,  it  is  well  recog- 
nized that,  very  often,  intercurrent  affections,  and 
organic  diseases  generally,  take  on  in  the  insane 
an  oscillatory  course,  or  even  a  latent  form,  so  that 


54  GEIiTEKAL    PATHOLOGY. 

they  may  pass  unperceived  and  only  be  recognized 
at  the  autopsy.  The  incidental  disorders  most  com- 
mon in  the  insane,  apart  from  cerel)ral  disorders,  are 
those  of  the  respiratory  apparatus,  tyj^hoid  fever, 
diarrhoea,  disorders  of  menstruation,  heart  disease, 
uterine  disorders,  etc. 

§  VI.     PROGNOSIS. 

The  prognosis  of  insanity  is  one  of  the  most  im- 
Ijortant  subjects  of  mental  pathology.  It  is  deduced 
from  the  characters  of  the  disease  and  from  certain 
particulars  in  regard  to  the  patient  himself. 

Prognosis  from  the  Character  of  the 
Disease. — Out  of  all  forms  of  mental  alienation  or 
insanity  only  the  generalized  tjq^es,  i.  e.,  mania  and 
melancholia,  are  curable.  The  systematized  insanities 
are  essentially  chronic,  and  recover  only  very  excep- 
tionally. A  favorable  j^rognosis  is  therefore  limited 
to  the  generalized  insanities,  which  frequently  recover. 
Indeed,  while  we  can  count  only  about  one  cure  to 
every  eight  or  jiine  cases  of  insanity  taken  at  random, 
tliis  proportion  changes  to  about  one  in  three  or  even 
more  if  we  exclude  the  incurable  forms. 

In  a  general  way,  the  more  acute  the  generalized 
insanity,  the  more  favorable  its  prospects.  Hence  it 
follows  that,  of  all  forms,  acute  mania  and  melan- 
cholia are  the  most  curable.  It  is  claimed  that  in 
acute  mania  there  are  at  least  seven  recoveries  out  of 
every  ten  cases.     Of  course  it  is  understood,  that  the 


PROG]S"OSIS.  55 

hyperacute  insanities  must  be  excluded  in  this  state- 
ment on  account  of  febrile  complications. 

The  less  generalized  and  intense  the  mania  or  melan- 
cholia,' the  less  is  their  chance  of  recovery.  The 
more  sudden  the  onset  of  the  disorder  and  the  quicker 
it  reaches  its  greatest  height,  the  better  are  the 
chances  of  recovery.  And  vice  versa,  the  longer  the 
period  of  incubation  and  the  more  lingering  the  pro- 
gress, the  more  serious  are  the  prospects. 

Further,  if  the  condition  of  excitement  or  de- 
pression remains  stationary  for  a  long  period,  the 
chances  of  cure  will  not  be  as  good,  as  when  glimmer- 
ings of  reason  and  moments  of  calm  occasionally 
occur.  Also  the  appearance  of  improved  nutrition, 
as  already  said,  not  coincident  with  a  parallel  im- 
provement mentally,  is  a  sign  of  bad  augury. 
Finally  the  existence  of  hallucinations,  particularly 
those  of  liearing,  the  creation  of  new  words,  the 
adoption  by  the  patient  of  a  pathological  language, 
of  a  costume,  of  a  special  attitude,  his  tendency  to 
collect  things,  to  fill  his  pockets,  to  deck  himself 
fantastically,  are  all  indices  of  threatening  incura- 
bility. It  is  not  necessary  to  mention  at  length  the 
disorders  of  menstruation,  the  menoj^ause,  and  inter- 
current diseases,  whose  action,  although  variable, 
may  influence,  in  some  instances,  the  course  of  the 
insanity. 

The  longer  the  disease  continues  it  is  evident  it  is 
the  less  curable.  The  chances  are  best  within  the  first 
six  months,  during  the  second  half   year  they  are 


56  GENERAL    PATHOLOGY. 

twice  as  bad ;  in  the  second  year  the  chances  of  cure 
diminish  to  about  one-sixth  of  the  figure  for  the  first 
half  year.  After  the  fourth  year  they  may  be  con- 
sidered as  ahnost  nil^  and  the  cases  reported  of  more 
or  less  delayed  recoveries  are  altogether  exceptional 
and  do  not  affect  the  rule. 

The  cause  of  the  disease  has  also  an  influence  on 
the  prognosis.  In  general  a  single  and  accidental 
cause  leaves  good  chances  for  recovery ;  multiple  and 
pennanent  causes  have  an  action  directly  opposite. 

Prognosis  Deduced  from  the  Patient  Him- 
self.— The  age  of  a  j^atient  is  not  a  matter  of  no 
importance ;  the  younger  he  is,  as  a  rule,  the  better 
his  chances.  Sex  has  likewise  some  influence :  women, 
indeed,  recover  more  often  than  men,  a  fact  due 
largely  to  the  rarity  in  them  of  general  paralysis. 
To  make  up  for  this,  they  are  more  often  subject  to 
relapses.  The  cause,  however,  inherent  to  the 
patient,  which  has  the  greatest  influence  on  the 
prognosis,  is,  Avithout  question,  the  absence  or  exist- 
ence of  predisposition  or  heredity.  Not  that  the 
subjects  of  heredity  and  the  predisposed  recover  less 
readily,  but  because  that  in  them  the  cure  is  seldom 
complete  and  permanent. 

Relapses. — Accoixling  to  most  authorities  re- 
lapses will  occur  in  the  proportion  of  12  or  14  to  the 
100,  and  are  es])ecially  frequent  within  the  first  year. 
Apart  from  liereditary  predisposition,  relapses  have 
their  origin  in  the  return  of  the  same  causes  that  pro- 


PATHOLOGICAL    AlSTATOlVrT.  57 

duced  the  original  disease,  morbidly  intense  emo- 
tions, suffering,  and,  in  needy  patients,  the  difHculty 
of  obtaining  work  after  leaving  the  asylum.  Usually 
it  is  the  same  form  of  insanity  as  before  and  some- 
times with  the  same  characters. 

§VII.     PATHOLOGICAL  ANATOMY. 

Has  insanity  corresponding  material  lesions,  or  not? 
In  order  to  answer  this,  it  is  necessary  to  first  settle 
the  limits  of  the  question,  and  to  exclude  all  the 
pathological  conditions,  such  as  alcoholism,  general 
paralysis,  neuroses,  etc.,  into  which  insanity  only 
enters  as  a  complication. 

1.  Pathological  Anatomy  of  Mental  Alien- 
ation IN  General.- — There  remains  mental  alien- 
ation, properly  speaking,  comprising  the  consti- 
tutional and  the  functional  alienation. 

The  constitutional  alienations,  congenital  or  ac- 
quired, i.  e.  idiocy,  cretinism,  imbecility,  and  demen- 
tia, are  usually  accompanied  by  manifest  material  alter- 
ations, affecting  the  whole  person,  but  more  especially 
the  cranium  and  the  nervous  centres.  To  cite  only 
the  principal  ones,  we  find,  absence  or  weakness  of 
an  organ  or  a  sense,  vicious  conformation  of  the 
cranium,  facial  asymmetry,  flattening  of  the  ears, 
arched  structure  of  the  palatine  vault,  prognathism, 
anomalies  of  the  genital  organs,  imi)uberty  and  ab- 
sence of  hair,  smallness  of  the  brain,  especially  the 
absence  or  diminution  of  certain  regions  or  convolu- 


58  GENERAL    PATHOLOGY, 

tions,  softening  in  places,  etc.,  etc.     Here  material 
lesions  exist,  frecjuently  very  gross  ones. 

Pathological  Anatomy  of  Insanity. — The 
question  is  harder  to  answer  in  regard  to  the  func- 
tional alienations  or  true  insanities,  and  there  are 
very  diverse  opinions  on  this  point. 

a. — Acute  Insanities. — It  appears  certain  that  in 
the  great  majority  of  cases,  the  acute  insanities  leave 
no  traces.  All  the  more  may  we  suppose  that  ma- 
niacal conditions,  or  those  of  excitement,  correspond 
to  a  hjq^ersemia,  and  melancholic  or  depressed  states 
to  an  ischa3mia  of  certain  regions  of  the  brain. 
Yet  these  purely  functional  disorders  usually 
disappear  at  the  autopsy,  so  that  they  cannot  always 
be  verified.  It  is  necessary  also  to  remember  that 
in  very  many  cases,  cerebral  hyperemia  and  isch- 
aemia,  or  congestion  and  anoemia,  are  insufficient  to 
produce  insanity.  We  have  therefore  to  admit  that 
lesions  are  lacking,  and  the  case  reported  by  Esquirol 
is  well  known  in  which  a  patient  in  full  tide  of  acute 
mania  was  killed  by  another  patient  by  blows  with 
a  sabot^  and  the  autopsy  revealed  no  alteration. 

Together  with  hyperajmias  and  sanguine  stases, 
serous  effusions  are  sometimes  met  with  in  acute  in- 
sanity. It  has  even  ])een  proposed  to  make  cerebral 
f edema  the  characteristic  of  one  particulai"  form  of 
mental  disease,  melancholia  with  stupor.  We  find 
also  occasionally  minute  haemorrhages,  some  men- 
ingeal, some  cortical. 


PATHOLOGICAL    ANATOftlT.  59 

b. —  Chronic  Insavities. — If  the  results  of  autop- 
sies of  acute  insanity  are  generally  negative,  the 
case  is  different,  at  least  usually,  with  chronic 
insanity. 

Frequently  this  disease  leaves  its  imprint  on  the 
extei'ior  foi"ni  of  the  brain.  There  is  atrophy  of  some 
regions,  flattening  of  the  convolutions,  especially 
anteriorly,  lacunae,  loss  of  substance  and  filling  of 
the  space  with  a  turbid  liquid.  We  have  noticed 
also  irregularity  of  the  first  and  second  frontal  con- 
volutions, hypertrophy  of  the  paracentral  lobe, 
widening  of  the  fissures,  etc.  The  weight  of  the 
brain  is  nearly  always  diminished,  and,  contrary  to 
the  usual  rule,  the  right  hemisphere  very  often 
weighs  more  than  the  left. 

Among  circulatory  disturbances  we  may  meet 
with  arterial  atheroma,  varicose  condition  and  fatty 
degeneration  of  the  capillaries,  vascular  alterations  of 
the  pia  mater  with  injection  of  its  network,  minute 
apoplexies,  varicose  condition  of  the  vessels,  milky 
patches  and  thickening  of  the  membranes,  adhesions 
of  the  meninges  to  each  other  and  to  the  cortex, 
hfematomas  of  the  dura,  etc. ,  etc. 

Among  cerebral  lesions,  properly  so-called,  Ave 
find  especially  degenerations  of  the  cells  and  nerve 
fibres,  sclerosis  of  the  neuroglia  and  more  or  less 
proliferation  of  the  same,  vascular  alterations  of  the 
opto-striate  bodies,  the  pons,  and  the  medulla, 
softening  or  sclerosis  of  certain  nerve  nuclei,  etc., 
etc. 


60  GENERAL    PATHOLOGT. 

Chemically  it  is  believed  that  the  water  in 
the  brain  is  increased  in  the  insane,  and  that 
fatty  substances,  on  the  other  hand,  are  in  less 
proj^ortion.  As  regards  phosphorus,  the  results  are 
negative. 


(Ibapter  ifll. 

SYMPTOMATIC   ELEMENTS   OF  MENTAL 
ALIENATION. 

Before  undertaking  the  description  of  tlie  various 
forms  of  mental  alienation,  it  is  necessary  to  first 
studj^  its  morbid  elements,.  In  order  to  do  this  satis- 
factorily, it  must  be  borne  in  mind  that  insanity  is  not 
merely  an  intellectual  disorder,  but  a  disease  aifecting 
the  whole  being,  and  that  consequently  its  constit- 
uent elements  may  exist  together  or  separately  both 
in  the  psychic  and  the  somatic  spheres. 

Division  of  the  Symptomatic  Eleme'nts. — 
Bearing  in  mind  the  above,  the  fundamental  division  of 
the  symptomatic  elements  of  alienation  seems  to  me 
to  be  based  on  the  fact  that  some  affect  onl}^  the 
functions  of  the  psycho-physique,  while  others  in- 
volve its  constitution.  Hence,  two  very  distinct 
groups  of  elements:  (1)  the  functional  or  dynamic; 
(2)  the  organic  or  constitutional  elements. 

§1.     FUNCTIONAL   ELEMENTS. 

These  elements  resolve  themselves  into  general 
disturbances  or  those  of  the  general  activity,  and 
partial  disturbances  referable  to  the  psychic  and  the 
physical  activities. 


6^  ELEMiiNTS    OF   MENTAL    ALIENATION. 

1.     Disorders  of  General  Activity. 

The  general  activity  is  the  total  of  the  systemic 
reactions  under  the  influence  of  psj^chic  impressions. 
It  may  be  abnormal  in  two  ways,  either  by  excess  or 
~by  default.  In  the  first  case  there  is  excitement^  in 
the  second  depression. 

Excitement.- — Excitement  consists  in  the  exalta- 
tion of  the  general  activity,  or  functional  reaction. 
When  very  intense  and  generalized,  it  reveals  itself 
in  a  disordered  activity  of  the  intelligence,  sensa- 
tions, and  acts  that  is  absolutely  uncontrollable.  If 
less  intense,  it  is  limited  to  a  simple  exaggeration  of 
the  normal  activity,  and  then  afl^ects  more  particu- 
larly the  psj^chic  or  the  motor  sphere.  It  is  tlie 
princii)al  element  of  maniacal  conditions,  the  varie- 
ties of  which  derive  then*  characters  from  its  degree 
of  intensit}''  and  generalization. 

Depression. — Depression  is  tlie  opposite  condi- 
tion to  excitement.  It  consists  in  a  defect  of  expan- 
sion of  tlie  general  activity,  which  ranges  from  sim- 
ple concentration  of  the  reaction  of  the  organism  to 
its  complete  suppression.  It  then  translates  itself 
externally  by  an  absolute  immobility  or  stui)or.  In 
a  minor  degree  it  ma}^  affect  more  ])articularly  either 
the  )>sychic  or  tlie  somatic  sphere.  Like  excite- 
ment it  is  characteristic  of  a  special  type  of  gen- 
eralized insanity,  the  conditions  of  lypemania  or 
melancholia. 


FUNCTIONAL    ELEMENTS.  63 

2.     Disorders  in  the  Psychic  Sphere. 

The  powerful  elements  of  insanity  in  tlie  psychic 
sphere  are:  (1)  of  tlie  intellect;  (2)  of  the  emotions ; 
(3)  of  the  motor  impulses. 

Disorders  of  the  Intellectual  Type. 

Of  these  we  have  to  describe :  «,  delusive  concep- 
tions; ^,   hallucinations;  c,   illusions. 

a. — Delusive  Conceptions. 

A  delusive  conception,  or  what  amounts  to  the 
same  thing,  delirium,  for  delirium  is  nothing  else  in 
the  individual  than  the  sum  total  of  his  delirious 
conceptions,  is  very  difficult  to  define.  If,  in  cer- 
tain cases,  the  delusive  ideas  are  absurd  or  unpossi- 
ble,  in  other  very  numerous  ones  they  have  noth- 
ing in  themselves  absurd  or  incompatible  with  the 
natural  order  of  things;  they  are  only  contrar}^  to 
fact,  and  irrational  in  the  mouth  of  the  person  utter- 
ing them.  A  man  believes  he  has  been  changed  into 
butter,  it  is  a  delusive  conception  and  also  an 
absurdity;  another  believes  himself  dishonored, 
ruined,  condemned ;  this  is  an  idea  that  involves  no 
impossibility,  and  is  only  delusive  in  respect  to  him 
who  believes  it  of  himself.  Leuret  says  truly:  ^'I 
have  sought  both  in  Charenton,  in  the  Bicetre,  and 
in  the  Salpetriere,  for  the  notions  that  appeared  the 
most  insane;  then,  when  I  have  com[>ared  a  number 
of  these    with    what    actually    occurs,   I  have  been 


64  ELEMENTS    OF    MENTAL    ALIENATION. 

altogether  surprised  and  almost  ashamed  at  not  per- 
ceiving the  difference." 

Delusive  conceptions  are  not  only  difficult  to  define 
because  they  are  far  from  being  always  absurd  in 
themselves,  but  also  because  it  is  not  always  easy 
to  distinguish  them  from  error.  The  difference 
does  not  consist,  as  has  been  claimed,  in  that  the  delu- 
sive idea  is  not  changed  in  spite  of  the  accumulation 
of  the  most  absolute  proofs  of  its  falsity.  There  are 
errors,  indeed,  that  are  held  more  tenacious^,  per- 
haps, than  delusions.  The  truth  is,  that  there  is 
not,  ^properly  speaking,  any  essential  difference 
betAveen  the  two,  and  that  the  delusion  is  separated 
from  mere  error  onl}"  by  its  causes  and  consequences, 
which  give  it  a  pathological  character  never  possessed 
by  the  other. 

Delusive  conceptions,  and  consequently  the  various 
delusions,  are  as  numerous  as  there  are  modes  of 
manifestation  of  human  thought.  Nevertheless  the 
principal  categories  of  delusions  met  with  in  insanity 
are  the  f  ollomng  (Ball  and  Ritti) : 

(1.)  Delusions  of  satisfaction,  of  grandeur,  of 
riches. 

(2.)  Delusions  of  humility,  despair,  ruin,  culpa- 
bility. 

(3.)  Delusions  of  persecution. 

(4.)   Hypochondriacal  delusions. 

(5.)  Religious  delusions. 

(6.)  Erotic  delusions. 

(7.)  Delusions  of  bodily  transformation. 


FUKCTIOIsTAL    ELEMENTS.  65 

The  delusive  idea,  being  only  a  symptomatic 
element  of  insanity  cannot  constitute  it  alone,  and 
enters,  only  as  a  part,  in  its  constitution.  There 
are  forms  of  insanity  without  delusions,  such,  for 
example,  as  those  that  have  been  called  reasoning- 
mania  and  impulsive  insanity. 

b.  — Hallucinations. 

Definition. — ' '  A  man,"  says  Esquirol,  ' '  who  has 
a  profound  conviction  of  actually  perceiving  a  sensa- 
tion, when  there  is  no  external  object  to  excite  that 
sensation  and  it  is  not  brought  through  any  of  his 
organs  of  sense,  is  in  a  state  of  hallucination."  M. 
Ball  abridges  this  definition  by  saying :  "  A  hallucin- 
ation is  a  sensation  without  an  object."  Thus  an 
individual  who  hears  voices  when  no  sound  strikes 
his  ear  has  a  hallucination.  We  may  say  also  that 
an  hallucination  is  an  idea  projected  externally,  an 
exteriorized  perception. 

Division. — Hallucinations  are  designated  accord- 
ing to  the  nature  of  the  sensation  perceived ;  there 
are  therefore  as  many  varieties  of  hallucinations  as 
there  are  senses.  In  case  of  those  senses  that  have 
a  double  and  symmetrical  organ,  like  hearing,  sight, 
tact,  the  hallucinations  may  affect  only  the  organ  of 
one  side :  it  is  then  unilateral.  When,  being  double, 
the  hallucination  takes  a  different  character  in  each 
of  the  two  sides,  it  niaj^  then,  it  seems  to  iis,  be 
properly  called  duplicated, 

Ment.  Med,— 5. 


66  ELEMENTS    OF    MENTAL    ALIENATION. 

There  are  liallucinations  involving  no  particular 
sense  organs,  such  cases,  for  example,  as  those  in 
Avhich  the  patients  sav  that  they  converse  soul  to 
soul,  without  language  of  any  sort.  Such  hallucina- 
tions in  which  the  sensorial  element  is  lacking  have 
been  designated  by  M.  Baillarger,  "psychic  hallu- 
cinations," and  byM.  Segias,  "psycho-motor  hallu- 
cinations. 

Nature. — The  nature  of  hallucinations  is  not  yet 
very  well  known.  There  are  three  theories  :  (1) 
the  psychic  theory,  which  makes  them  purely 
intellectual,  the  revival  of  an  idea ;  (2)  the  physical 
theory  that  makes  them  a  purely  physical  and  organic 
phenomenon ;  and  (3)  the  mixed,  or  psycho-sensorial 
theory,  which  admits  in  their  production  at  once  a 
sensory  and  a  psychic  element.  It  is  the  last  of  these 
that  counts  the  most  supporters. 

The  intervention  of  a  physical  element  in  the 
genesis  of  hallucinations  is  made  beyond  a  doubt  by 
the  finding  of  various  lesions  in  the  sensory  organs 
involved,  in  their  nerves,  in  the  thalami  and  the 
coi*pora  striata,  in  sensory  centres  in  the  cortex ;  by 
the  alteration,  in  unilateral  hallucinations,  of  the 
peripheral  or  central  portion  of  the  sense  organ  of 
the  affected  side;  and  finally  by  experiments  with 
})rovoked  hallucinations  in  hysterical  cases. 

There  is  a  constantly  increasing  tendency,  at  pres- 
ent, to  locate  the  seat  of  liallucinations  in  the  per- 
ceptive centres  of  the  cerebral  cortex.  This  is  the 
view  held  by  Tamburini,   by  Fere  and  Binet,  by 


FUNCTIONAL    ELEMENtS.  67 

Ballet,  and  by  Seglas,  who,  in  a  recent  memoir, 
divides  hallucinations  into  psycho-sensorial  and  psy- 
cho-motor (verbal,  visual  and  auditory),  according 
as  the  sensory  or  the  motor  centres  of  the  cortex  are 
involved.  A  Russian  physician.  Dr.  Kandinsky,  who 
suffered  from  an  attack  of  lypemania,  analyzed  in 
himself  the  mechanism  of  hallucinations,  and  also 
attributes  them,  conformably  to  Meynert's  theory, 
to  a  subjective  or  automatic  stimulation  of  the  cor- 
tex of  the  anterior  lobes  of  the  brain. 

Hallucinations  without  Insanity. — Like  de- 
lusions, hallucinations  are  only  symptomatic  elements 
of  insanity,  and  do  not,  by  themselves  alone,  consti- 
tute it.  Moreover,  hallucinations  may,  in  some  cases, 
exist  without  insanity,  and  sane  persons  are  subject, 
especially  at  the  moments  of  passage  between  sleep- 
ing and  waking,  to  hallucinations  which  they  appre- 
ciate very  sanely  (hypnagogic  hallucinations). 
Nevertheless  these  phenomena  have  been  incorrectly 
called  physiological  hallucinations.  A  hallucination 
is  always  a  morbid  phenomenon ;  it  is  only  its  inter- 
pretation that  can  be  either  physiological  or  patho- 
logical. 

Hallucinations  occur  in  many  forms  of  insanity, 
and  it  is  not  possible  to  separate  a  special  type  under 
the  name  of  hallucinatory  insanity.  They  are  especi- 
ally frequent  in  melancholia,  persecutory  insanity, 
toxic  insanities,  etc. 

Hallucinations  of  Hearing. — Auditory  hallu- 
cinations are  most  frequently  met  with  in  insanity. 


68  ELEMENTS    OP    MENTAL    ALIENATION. 

They  are  a  grave  symptom,  and  may  serve  as  a 
criterion  to  distinguish,  in  a  general  way,  the  dan- 
gerous hinatics.  Every  subject  of  auditory  haUu- 
cinations  is,  it  may  be  said,  an  essentially  dangerous 
patient.  They  are  frequently  met  with  in  melan- 
cholia, but  are  most  frequent  in  insanity  with  delu- 
sions of  persecution,  in  Avhich  form  they  are  the 
characteristic  symptom. 

An  auditory  hallucination  consists  essentially  in  the 
perception  of  fictitious  sounds.  These  may  be  con- 
fused and  inarticulate ;  but  they  rarely  continue  thus ; 
after  lasting  a  short  time  the  hallucination  organizes 
itself,  becomes  articulate,  and,  to  use  the  common 
expression  of  the  patients,  it  becomes  a  voice. 

These  voices  may  be  unknown  to  the  patients  as 
to  sound  and  intonation,  but  are  frequently  recog- 
nized by  them  as  belonging  to  their  parents,  friends, 
or  such  and  such  a  person  as  they  designate.  They 
may  also  belong  to  imaginary  persons,  to  the  defunct, 
to  God,  the  devil,  the  Virgin,  the  saints,  etc. 
Animals  and  inanimate  objects  even  are  charged 
with  conversing  by  patients. 

The  voices  may  say  pleasant  things  to  the  patients, 
but  more  often  the  hallucinations  have  a  distressing- 
character,  and  consist  in  insults,  reproaches,  men- 
aces, accusations,  etc.  Many  patients,  those  with 
delusions  of  persecution  more  especially,  complain 
that  they  have  their  thoughts  repeated  aloud,  and 
mostly  those  they  most  desire  to  hide,  and  also 
that   the   most  secret  acts   of   their  life   are   told. 


FUNCTIONAL    ELEMENTS.  69 

This    phenomenon    bears    the    name    of    ecJio    of 
thoicght. 

The  direction  of  the  voices  is  very  variable.  They 
may  come  from  above  or  below,  from  one  side  or  the 
other,  from  before  or  behind,  and  even  from  the 
patient's  body  itself.  In  the  last  case  they  have 
sometimes  the  effect  finally  to  give  rise  in  the  patient's 
mind  to  the  idea  that  he  is  double,  and  thus  originate 
that  curious  condition  known  as  duplication  of  the 
personality.  The  distance  from  whence  they  come 
is  also  variable,  and  the  hallucinated  individuals  are 
quite  certain  as  to  their  distance,  they  estimate  it 
sometimes  as  a  metre  or  two,  sometimes  hundreds  of 
kilometres. 

The  voices  are  so  natural  and  the  conviction 
of  their  existence  is  so  irresistible,  that  very  intelli- 
gent patients,  physicians  and  alienists  themselves, 
will  not  suffers  doubt,  and  have  recourse,  in  explain- 
ing their  existence,  to  all  kinds  of  absurd  and  incredi- 
ble interpretations ;  for  example,  to  the  intervention 
of  various  forces,  electricity,  acoustic  tubes,  the 
telephone,  phonograph,  etc.,  etc. 

The  language  of  the  voices  is  usually  the  ordinary 
one,  and  the  words  those  of  the  current  vocabulary. 
Nevertheless  they  may  be  in  a  foreign  or  unknown 
tongue.  The  well-known  case  reported  by  Esquirol 
is  in  point,  of  an  insane  polyglot  who  heard  them 
speak  many  languages,  but  become  confused  when 
they  used  one  with  which  he  was  little  acquainted. 
Ball  has  reported  an   analogous  case.      Finally  the 


70  ELEMENTS    OF    MEXTAL    ALIENATION. 

voices  may  manufacture  words,  pronounce  neolog- 
isms, which  then  pass  into  the  speech  of  the  patient, 
constitutino-  gradually  a  new  vocabulary.  This  is 
then  a  sign  of  chronicity.  Hallucinations  of  hear- 
ing are  often  connected  with  other  hallucinations. 

The  actively  hallucinated  patients,  those  who  are 
always  conversing  with  their  voices,  often  have  a 
peculiar  physiognomy  that  is  recognizable  after  some 
experience.  The  characteristic  is  the  brightness  of 
the  eyes,  wide  open,  fixed  and  brilliant,  which  can  be 
best  compared  to  the  appearance  of  a  man  al)Sorbed 
in  thought  who  sees  without  taking  notice.  More- 
over in  following  these  patients  one  remarks  that 
they  are  talking  with  imaginary  personages.  Thus 
they  laugh  at  wliat  they  hear  or  rei3ly  to  the  voices, 
either  aloud  in  more  or  less  broken  exclamations,  or 
silently  by  simph^  moving  their  lips.  Finally  they 
are  liable  to  do  sudden,  violent  or  dangerous  actions 
caused  by  their  hallucinations. 

In  closing  the  sul>ject  of  auditory  hallucinations, 
it  is  well  to  add  that  deafness  is  no  obstacle  to  their 
production.  On  the  contrary  nearly  all  the  insane 
wlio  are  deaf  or  liard  of  hearing,  have  auditor^'' 
hallucinations.  It  may  be  the  same  with  the  other 
senses. 

Hallucinations  of  Sight. — Visual  hallucinations, 
less  common  than  those  of  hearing,  present  analogous 
characters  and  hardly  differ  in  that  they  constitute 
a  less  serious  symptom,  and  that  they  are  character- 
istic uf  certain  special  forms  ol"  insanity,  such  as  the 


FUNCTIONAL    ELEMENTS.  71 

toxic  and  neuropathic  forms.  Hallucinations  of 
sight  may  consist  in  visions  of  persons  and  objects  of 
the  most  varied  character,  landscapes,  animals, 
phantoms,  monsters,  etc.  They  take  on,  in  certain 
cases,  a  terrifying  character. 

Hallucinations  of  Smell  and  Taste. — The 
hallucinations  of  smell  and  taste  are  the  most  in- 
frequent of  all.  They  are  met  with  especially  in 
certain  forms  of  melancholia,  in  hypochondria,  some- 
times also  in  the  insanity  of  persecution ;  they  fre- 
quently co-exist  with  a  saburral  condition  of  the 
digestive  tracts,  and  ordinarily  carry  with  them 
refusal  of  food.  The  patients  may  experience  strange 
odors  and  tastes,  such  especially  as  those  of  arsenic, 
copper,  sulphur,  ammonia,  rotten  eggs,  etc.  Some- 
times they  fancy  that  they  themselves  give  out 
frightful  odors  and  condemn  themselves  under  the 
influence  of  this  idea  to  live  alone  apart  from 
society. 

Hallucinations  op  General  Sensibility.  Gen- 
ital Hallucinations. — Hallucinations  of  general 
sensibility  are  rather  frequent  in  insanity,  especially 
with  delusions  of  persecution.  They  consist  in  the 
sensation  of  shocks,  electric  commotions,  of  being- 
lifted  in  the  air,  which  the  patients  interpret  accord- 
ing to  their  delusions.  We  may  denominate  certain 
hallucinations  genital  which  cause  all  kinds  of 
voluptuous  or  painful  sensations  in  the  genital 
organs. 


72  ELEMENTS    OF    MENTAL   ALIENATION. 

c. — Illusions. 

Definition. — Illusion  is  a  morbid  phenomenon 
rather  common  in  insanity.  It  is  not,  like  hallucina- 
tions, a  perception  without  an  ol)ject,  but  is  an 
erroneous  perception ;  it  is,  if  a  closer  definition  is 
required,  the  false  interpretation  of  a  perceived 
sensation.  As  has  been  stated,  a  person  who  hears  a 
voice  when  none  strikes  his  ear  has  an  hallucination. 
If  he  hears  the  sound  of  a  bell,  for  example,  but 
fancies  that  it  is  an  insult  that  is  addressed  to  him, 
he  has  an  illusion.  Lasegue  has  very  aptly  pointed 
out  this  distinction  between  an  illusion  and  a  halluci- 
nation, in  the  following  :  An  illusion  is  to  a 
hallucination  what  innuendo  is  to  calumny.  The 
illusion  is  based  on  a  truth  which  is  embellished,  the 
hallucination  is  a  pure  invention,  there  is  no  truth 
in  it. 

Characters.  Division. — An  illusion,  still  more 
than  a  hallucination,  is  a  i^sychic  phenomenon,  since 
in  it  the  sensory  perceptions  are  altogether  normal 
and  it  is  only  the  intelligence  that  is  in  fault.  As 
has  been  well  said  by  M.  Descourtis,  in  a  memoir 
yet  unpublished  (Civrieux  Prize,  1889,  Hallncina- 
tions  of  HPAJbTing)^  illusions  are  not  eiTors  of  the 
senses;  they  simply  constitute  a  form  of  delusion. 

As  regards  prognosis,  illusion  is  not  so  grave  a 
symptom  as  hallucination.  It  is  very  common  in  the 
curable  forms  of  insanity,  especially  in  acute  mania 
and  intoxications. 


I'UNCTIOKAL    ELEMENTS.  73 

Illusions,  like  hallucinations,  are  classed  according 
to  the  special  senses  which  are  the  point  of  departure 
of  the  phenomenon.  Unlike  hallucinations,  illusions 
of  sight  are  altogether  the  most  frequent.  They 
may  be  also  unilateral. 

INTERNAL  Illusions. — There  is  a  special  class  of 
illusions  which  cannot  be  properly  referred  to  any  of 
the  special  senses,  and  which  are  known  by  the  name 
of  internal  or  coensesthetic  illusions.  They  consist 
in  false  interpretations  of  actual  organic  sensations. 
Thus,  very  frequently,  affections  of  the  intestines, 
the  stomach,  or  the  uterus,  induce  in  patients,  by  the 
reactions  they  cause,  ideas  that  they  have  animals 
in  their  bellies,  that  they  have  been  violated,  etc., 
etc.  These  internal  illusions  are  especially  frequent 
in  the  so-called  sympathetic  insanities. 

Mental  Illusions. — Another  class  of  non-sensory 
illusions,  very  frequent  in  acute  mania,  is  made  up 
of  illusions  of  persons,  objects,  surroundings,  some- 
times awakened  by  some  vague  resemblance,  but 
more  often  by  a  simple  association  of  ideas.  These 
are  purely  mental  illusions. 

Scientifically,  illusions  are  not  clearly  separated 
from  hallucinations,  and  it  is  sometimes  difficult  to 
class  the  morbid  phenomenon  under  one  or  the  other 
of  these.  Clinically,  however,  the  distinction  is  a 
necessary  one  and  should  be  preserved. 

There  are  other  intellectual  phenomena,  such,  for 
example,  as  the  disorders  of  memory,  of  attention,  of 


74  ELEMENTS    OF    MENTAL    ALIENATION. 

the  will,  etc. ,  tliat  are  very  common  in  insanity,  but 
these  are  not  primary  elements,  they  are  complex 
phenomena,  more  often  consecutive,  and  their 
description  belongs  more  properly  in  works  on 
psychology.  They  have  been  learnedly  discussed 
by  Theodore  Ribot  in  his  remarkable  monographs. 

Disorders  of  the  Emotions. 

Disorders  in  the  sphere  of  the  emotions  are,  so  to 
speak,  constant  in  mental  disease  and  constitute  a 
true  moral  insanity,  corresponding  with  the  in- 
tellectual disorder. 

The  insanity  of  the  feelings  and  affections  is  not 
of  itself  more  necessarily^  absurd  than  is  that  of  ideas ; 
its  pathological  character  is  derived  entirely  from  the 
fact  that  it  is  not  in  accordance  with  tlie  actual 
situation  of  the  individual.  There  are  as  many  in- 
sane types  of  feeling  as  there  are  modes  of  activity 
in  the  emotional  nature  of  man.  The  princii^al  aberra- 
tions met  with,  of  this  kind,  in  insanity  are,  apart 
from  disorders  of  affections,  strictly  speaking,  which 
are  almost  constantly  encountered : 

1.  Egoism^  which  is  often  the  fundamental 
character  of  the  insanity. 

2.  Pride ^  which  is  observed  especially  in  ambi- 
tious insanity. 

3.  Malice^  knavery^  deceitfulness  and  falsity^  in 
reasoning  mania. 

4.  Rebelliousness^  hatred  and  revenge^  in  delu- 
sions of  persecution. 


FUNCTIONAL    ELEMENTS.  75 

5.  Generosity  ^philanthropy  2uW^^  prodigality  ^  in 
general  paralysis  with  expansive  delusions. 

6.  Discouragement^  weakness^  in  intellectual 
and  moral  hypochondria. 

7.  Humility^  contrition^  apprehensiveness^  terror, 
in  melancholia  and  its  various  forms. 

8.  Anxiety,  also  in  melancholia  and  in  emotional 
neurasthenias. 

The  disordered  feelings,  which  in  their  total  form 
moral  insanity,  give  to  patients  in  each  form  of 
mental  disease,  a  special  character,  that  is  too  often 
overlooked  in  giving  attention  to  the  intellectual 
disturbances.  There  are  certain  forms,  reasoning- 
mania  for  example,  in  which  the  moral  insanity 
alone  exists,  without  any  marked  involvement  of  the 
intellect. 

Motor  Disordees. 

In  the  psycho-motor  sphere  we  have  to  do  with 
disorders  of  the  instincts  and  those  of  acts. 

a. — Instinctive  Insanity. 

The  different  instincts  often  undergo  changes  in 
insanity,  analogous  to  those  of  the  intellect  and  the 
emotions. 

These  changes  are  extremely  various.  The  most 
common  are  those  involving  the  sexual  instinct,  and 
show  themselves  by  all  kinds  of  sexual  depravity, 
such  as  sodomy,  saphism,  bestiality,  voluntary 
mutilations,  reversed  sexual  instinct  {contrdre 
sexual  Mnpji^ulung) ;  violations  of  cadavers,  etc. 


76  ELEMENTS    OF    MENTAL    ALIENATION. 

The  instinct  of  self-preservation  is  likewise  fre- 
quently impaired  in  insanity,  and  there  are,  it  is  well 
known,  some  patients  who,  without  having  a  positive 
tendency  to  suicide,  would  not  make  a  movement  to 
protect  themselves  from  imminent  death.  Such  cases 
were  recently  observed  in  the  burning  of  the  asylum 
at  Montreal  in  Canada  (May  5,  1890). 

h. — Insanity  of  Acts. 

In  the  same  way  that  disordered  intellection  and 
emotions  constitute  intellectual  and  emotional 
insanities,  properly  speaking,  so  disordered  action  in 
mental  alienation  constitutes  the  insanity  of  acts 
(deli7'e  des  actes). 

Among  insane  actions  there  are  some  that  are 
absurd  in  themselves,  others  are  not  per  se  illogical, 
and  are  only  so  in  that  they  do  not  fit  the  actual  con- 
dition of  the  actor.  All  possible  acts  may  therefore 
become  morbid  in  special  cases,  so  that  insane  acts 
are  innumerable. 

Those  most  frequently  seen  in  insanity  are  : 

1.  Acts  of  impoliteness  or  impropriety,  obscene 
exhibitions,  tendencies  to  eat  filth  and  excrements 
(skatophagia) ,  which  are  met  with  especially  in 
demented  conditions. 

2.  Acts  of  violence,  destructiveness,  of  sudden 
and  blind  fury,  most  special  to  maniacal  conditions 
and  epilepsy. 

3.  Refusal  of  food,  suicide,  almost  peculiar  to 
melancholia. 


FUNCTIONAL    ELEMENTS.  77 

4.  Homicide,  especially  frequent  with  delusions 
of  persecution,  epilepsy,  etc. 

5.  Theft,  incendiarism,  in  states  of  dementia, 
imbecile  furor,  epilepsy,  etc. 

As  regards  consequences,  morbid  acts  resolve 
themselves  into  dangerous  and  non-dangerous. 

As  regards  their  nature  they  are  distinguishable 
into  reflex  acts  and  irresistible  or  impulsive  actions. 

Impulsions.— A  morbid  impulse  is  an  irresistible 
tendency  to  perform  an  action. 

In  the  normal  condition  every  sensation  tends  to 
translate  itself  with  an  action,  but  this  tendency  is 
restrained  by  the  ego^  which  intervenes,  perceives 
the  sensation,  analyzes  it,  and  finally  decides  for  or 
against  the  accomplishment  of  the  act.  •  The 
equilibrium  between  the  tendency  to  the  act  and  the 
restraining  power  of  the  ego  (determinism),  consti- 
tutes the  normal  condition  in  this  point  of  view. 
The  impulse  results  from  a  rupture  of  this  equilibrium. 

The  equilibrium  being  lost,  either  by  weakness  of 
of  the  ego^  or  by  an  increase  of  the  tendency  to  re- 
flex action,  or  by  both  together,  it  follows  that 
the  impulse  may  be  the  consequence  of  one  or 
other  of  these  conditions,  hence  it  occurs  in  those 
forms  of  alienation  in  which  it  is  observed.  Practi- 
cally, it  is  especially  in  the  emotional  neurasthenia, 
the  degenerative  conditions,  imbecility,  dementia, 
(enf  eeblement  of  the  ego) ,  acute  mania,  hallucinatory 
insanities  (exaggerated  reflex  tendency) ,  and,  finally, 
in  epilepsy^ (mixed  state),  that  we  meet  with  impul- 


78  ELEMENTS    OF    MENTAL    ALIENATION. 

sions.  Impulsions  divide  into  besetting  impulses  (ob- 
sessions) and  reflex  impulses  (impulsions,  properly 
socalled) ,  according  as  they  act  with  or  without  resist- 
ance on  the  part  of  the  individual.  They  may  also 
be  divided  into  intellectual,  emotional,  or  motor  im- 
pulsions, according  to  the  sphere  affected. 

Motor  impulsions,  which  are  those  generally  re- 
ferred to  in  the  clinique  Avhen  we  speak  of  impulsions, 
are,  further,  designated  by  the  morbid  acts  to  which 
they  give  rise.  Thus  we  speak  of  impulsion  to  theft 
(kleptomania) ,  to  incendiarism  (pyromania) ,  to  drink 
(dipsomania),  to  murder,  suicide,  etc.,  etc.  At  one 
time  there  was  a  tendency  to  consider  each  form  of 
impulsion  as  an  insanity,  a  special  monomania;  now- 
a-days  that  is  completely  abandoned,  and  it  is -gener- 
ally admitted  that  morbid  impulse  is  only  a  symp- 
tomatic element  of  insanity,  that  may  occur  under 
different  characters,  in  widely  differing  conditions. 

3. — Physical  Disorders.* 

The  symptomatic  elements  of  insanity  in  the 
physical  sphere  may  involve  the  nervous  functions 
and  those  of  vegetative  life. 

Disorders  of  the  Nervous  Functions. 

The  principal  disorders  of  the  nervous  functions 
are  those  that  affect  sleep,  sensibility  and  motility. 

*In  the  preparation  of  this  part  of  the  chapter,  much 
abridged  in  the  first  edition,  I  have  utilized  with  especial 
profit  the  excellent  Manual  cle  Semeiologie  Psycliiatrique  of 
Prof.  Morselli  of  Turin,  1885. 


FUNCTIONAL    ELEMENTS.  79 

a. — Sleep. 

Sleep  is  one  of  the  functions  most  constantly 
affected  in  insanity.  In  acute  attacks,  insomnia  is 
one  of  the  first  symptoms  to  appear ;  it  reveals  itself 
particularly  in  agitation,  dreams  and  nightmares. 
On  the  other  hand,  the  return  of  sleep,  at  the  end  of 
an  attack  of  mania  or  melancholia,  is  an  excellent 
augury,  and  can  pass  for  one  of  the  most  certain 
indices  of  approaching  recovery,  except  always  in 
those  cases  where  this  return,  in  connection  with  the 
re-establishment  of  the  processes  of  assimilation, 
does  not  coincide  with  a  parallel  improvement  of  the 
mental  condition.  Insomnia  is  infrequent  in  chronic 
insanity,  excepting  in  patients  with  hallucinations  or 
coenaesthetic  illusions. 

The  power  of  endurance  of  insomnia  of  the  insane 
sometimes  attains  a  surprising  degree.  We  see  them 
pass  whole  weeks  without  sleep  whatever  means  are 
employed  to  produce  it.  This  absolute  and  complete 
loss  of  sleep,  which  may  depend  upon  a  loss  of  the 
sense  of  fatigue,  is  generally  a  bad  prognostic,  since 
it  is  due  to  a  profound  alteration  of  the  nervous 
centres. 

The  question  arises  whether  the  insane  have 
dreams  connected  with  their  disorder.  This,  in 
itself  probable,  has  been  put  beyond  doubt  by 
many  observers. 

Dreams  have,  moreover,  very  direct  relations 
with  insanity.  Besides  the  h3^p^agogic  hallucina- 
tions, already  mentioned,  occurring  in  the  semi-wak- 


80  ELEMENTS    OF    MENTAL    ALIENATION. 

ing  conditiou,  it  is  well  known  that  both  dreams 
and  insanity  take  their  source  in  the  involuntary  or 
automatic  exercise  of  the  cerebral  functions.  It  has 
been  demonstrated  further  that  the  delusions  of  in- 
sanity may  follow  the  images  of  the  dreams  in  such 
a  way  as  to  be  at  once  their  psychological  and 
and  chronologic  continuations  (Lasegue,  Chaslin). 
Finally  there  are  observations  that  tend  to  show 
that  dreams  may  sometimes  be  a  precursory  sign  and 
reveal  more  or  less  in  advance  a  coming  disease, 
such  as  a  neurosis  or  mental  alienation. 

b.  — Bensihility. 

The  disorders  of  sensibility,  by  their  importance 
and  frequency,  play  a  very  important  part  in  mental 
disease.  We  may  divide  them,  for  convenience  of 
study,  into  disorders  of  special  sensation  (external 
sensations),  and  those  of  organic  sensibility  (internal 
sensations) . 

Special  Sensation  (external  sensation). — The 
cutaneous  sensibility  may  exhibit  notable  alteration 
in  the  insane.  There  is  notwithstanding  an  important 
distinction  to  be  made  here.  It  is  not  usually  the 
tactile  sensibility,  strictly  speaking,  that  is  modified, 
that  which  gives  us  notions  of  form,  direction,  con- 
sistence, position,  and  resistance  of  objects,  tliat  is 
commonly  intact.  What  is  impaired  is  the  sensibility 
to  physical  agents,  heat,  pain,  electricity,  etc.  These 
various  sensibilities,  which  probably  have  their  own 
special  conductors,  and  whose  alteration  seems  to  be 


INUNCTION  AL    ELEMENTS.  81 

located  in  the  cerebral  cortex,  may  be  simultaneously 
or  singly  affected. 

Cutaneous  hyperaesthesia  is  rarer  in  insanity  than 
anaesthesia.  It  may  be  encountered,  nevertheless,  in 
mania,  and  in  toxic  insanities,  where  it  is  often 
limited  to  certain  parts  of  the  body,  but  before  all  in 
the  systematized  insanities,  where  it  often  becomes 
the  point  of  departure  of  tegumentary  hallucinations 
that  are  designated  under  the  name  of  disorders  of 
general  sensibility. 

Anaesthesia,  much  more  common,  may  be  general 
or  local,  slight  or  pronounced.  In  the  latter  case 
there  is  almost  complete  insensibility  of  the  whole 
external  surface,  as  in  certain  forms  of  stupor.  It 
may  involve  the  tactile  sensibility,  but  it  is  difficult 
to  estimate  it  accurately  in  the  insane,  on  account  of 
the  retardation  of  sensation  which  seems  to  be  rather 
frequent  in  them.  Ziehen  has  observed,  in  general 
paralytics,  a  lesion  of  memory  of  sensations,  on 
account  of  which  they  cannot,  after  a  few  seconds, 
localize  correctly  any  more  the  prick  of  a  pin.  This 
symptom,  which,  according  to  that  authority,  often 
is  present  from  the  beginning  of  the  disorder,  may 
be,  in  some  cases,  useful  for  diagnostic  purposes. 
The  more  ordinary  anaesthesia  in  the  insane  is  that  to 
temperature  and  pain  (analgesia).  Nothing  is  more 
surprising  than  the  ease,  one  might  say  the  indiffer- 
ence, with  which  the  majority  of  the  insane  endure 
excessive  cold,  heat,  burns,  wounds,  operations  of  all 

kinds;    it    seems    as   if     they    felt   nothing.     This 
Ment.  Mbd.— 6. 


82  ELEMENTS    OF   MENTAL    ALIENATION. 

explains,  at  least  in  part,  their  desire  to  unclothe 
themselves,  the  resistance  they  oppose  to  diseases  a 
frigore^  and  the  stoicism  they  occasionally  exhibit 
in  the  most  frightful  sufferings.  In  .  some  the 
susceptibility^  to  cold,  which  disappeared  at  the  onset 
of  the  insanity,  reappears  at  the  moment  of  recovery. 
We  encounter  anaesthesia  more  especially  in  torpid 
melancholia,  depressive  general  paralysis,  the  toxic 
insanities,  the  degenerations  and  conditions  of  mental 
weakness. 

There  are  but  few  accurate  data  in  regard  to  the 
electrical  sensibility  of  the  insane.  It  is  known, 
however,  that  it  may  be  increased  or  diminished, 
and  that  its  alterations  go  most  frequently />«r^pc^s's?/ 
with  the  tactile  sensibility.  In  some  cases,  never- 
theless, we  find  electrical  hj'3)eralgesia  or,  more  often, 
analgesia  without  any  corresponding  modification  of 
the  local  cutaneous  sensibility.  M.  Seglas  has  re- 
cently observed,  as  a  special  symptom  of  lypemauia, 
an  increase  of  electrical  resistance,  that  sometimes 
attains  a  high  figure  (70,000  ohms).  This  resist- 
ance is  more  marked  in  the  stuporous  than  in  the 
anxious  form. 

The  magnetic  sensibility  (action  of  magnets)  has 
been  found  exaggerated,  as  is  well  known,  in  hys- 
teria, and,  in  a  general  way,  in  the  neuropathies. 
In  the  insane,  it  seems  proven  that  it  is  generally 
augmented,  especially  in  melancholia.  The  same  is 
the  case  with  the  metallic  sensibility  (metalloscopy). 

The   meteoric  sensibility    (action   of  cosmic   and 


I'UNCTIOlSrAL    ELEMENTS.  83 

telluric  variations) ,  which  is  very  marked  in  the  neu- 
ropathies, is  still  more  so  amongst  the  insane,  mainh^^ 
as  regards  the  return  of  periodic  attacks,  and  in 
epilepsy. 

The  special  senses,  independently  of  hallucinations 
and  illusions  already  described,  may  undergo  more 
or  less  pronounced  changes  in  insanity. 

The  gustatorj^  sense  may  be  increased  (liyper- 
geusia) ,  diminished  (hypogeusia) ,  or  abolished  (ageu- 
sia), principally  in  neuropathic  and  toxic  insanity, 
melancholia  with  sitiophobia,  and  the  organic  and 
tabetic  dementias.  It  may  also  be  perverted  (par- 
ageusia). This  is  what  occurs  in  some  melancholiacs 
and  many  hallucinated  cases,  who  profess,  for 
example,  a  great  horror  of  meat  and  thus  become 
vegetarians. 

The  olfactory  sense  is  likewise  found  exalted 
(hyperosmia),  diminished  (hyposmia),  or  abolished 
(anosmia),  in  certain  conditions  of  insanity,  especially 
m  hysteria,  localized  cerebral  disease,  jiaralytic  de- 
mentia, systematized    insanity,   and,   lastly,  mania. 

Not  uncommonly  the  defect  is  localized  in  one 
nostril  (hemianosmia) ,  for  example,  in  the  beginning 
stage  of  general  paralysis  (Voisin).  Finally,  we  en- 
counter in  nearly  every  form  of  insanity,  perversions 
of  the  sense  of  smell  (paraosmia)  which  often  form 
the  substratum  of  hallucinations  and  illusions  of 
this  sense. 

As  regards  the  sense  of  hearing,  we  find  in  many 
insane,    either    its    exaltation    (hyperacusia) ,    dimi- 


84  ELEMENTS    OF   MENTAL   ALIENATION.    . 

imtion  (liypoacusia)  or  its  perversion  (paracusia). 
Hysteria,  ecstasy,  the  hypnotic  condition,  febrile 
delirium,  and  acute  mania,  are  most  frequent!}"  ac- 
comjjaniedby  acoustic  hyperesthesia;  the  depressive 
and  stuporous  melancholias  and  localized  encephalitis 
rather  give  rise  to  its  hypoiesthesia.  Paracusia  is 
characteristic  of  hallucinatory  and  congestive 
insanity,   hypochondria,   and  neurasthenia. 

The  anomalies  of  visual  sensibility  are,  of  all,  the 
most  variable  and  most  frequent  in  the  insane.  We 
observe  optic  hyperaesthesia  (photopsia,  chromop- 
sia)  in  diffuse  encephalitis  and  states  of  excitement ; 
optic  hj^posesthesia  (amblyopia,  hemiopia,  diplopia) 
in  the  complicated  or  secondary  forms  of  insanity, 
general  paralysis,  tabetic  dementia,  intoxications, 
hysteria,  epilepsy,  and  neurasthenia;  optic  ana?s- 
thesia  (blindness,  amaurosis)  in  mania  and  general 
paralysis;  optic  parsesthesia  (color  blindness,  Dal- 
tonism, nyctalopia,  hemeralopia)  in  sensorial  delirium, 
alcoholic  insanity,  systematized  insanity,  epilepsy, 
and  hysteria. 

The  muscular  sense  and  the  reflexes  are  not, 
properly  speaking,  a  part  of  the  special  sensibility, 
but  their  alterations  in  mental  disease  may,  never- 
theless, be  mentioned  here. 

In  the  insane  the  muscular  sense  is  usual!}'  exalted 
in  excited  states  of  mania,  and  it  is  doubtless  owing 
to  this,  in  great  part,  that  certain  patients  are  able 
to  undergo  continuous  and  intense  exertions  without 
feeling  the  least  fatigue.      On  the  other  hand,  the 


FIJNCTIOlSrAL    ELEMEIS^TS.  85 

muscular  sense  is  always  more  or  less  diminished 
in  states  of  depression  or  melancholia,  and  this 
explains  the  lack  of  action,  the  prolonged  atti- 
tudes, and  the  cataleptiform  immobility  of  some 
among  them  who  seem  to  have  changed  to  veritable 
statues. 

With  this  hypersesthesia  and  anaesthesia  of  the 
muscular  sense  we  have  also  parsesthesia  or  perver- 
sion, which  indicates  a  more  or  less  profound  disorder 
of  the  sentiment  of  personality.  The  patients 
believe  their  limbs  or  bodies  are  extraordinarily 
enlarged  or  diminished,  are  made  of  glass,  wood, 
or  metal,  and  therefore  do  not  dare  to  move  (acute 
hallucinatory  conditions,  katatonia,  hebephrenic 
stupor) . 

The  sense  of  equilibrium,  which  may  be  compared 
to  the  muscular  sense,  although  its  origin  is  more 
complex,  presents  two  kinds  of  alterations  in 
insanity.  Sometimes  these  alterations  are  transitory 
and  accidental  epiphenomena  of  the  organic  nervous 
changes  (insanit}''  from  cerebral  traumatism,  peri- 
encephalitis, tabes  dorsalis,  cerebral  tumors  and  syph- 
ilis, chronic  intoxication,  and  epilepsy) ;  sometimes 
they  form  true  symptoms  of  an  exclusively  psychic 
character,  and  reveal  themselves  either  by  the  loss 
or  anaBvSthesia  of  the  sense  of  equilibrium  (melan- 
cholia, stupor,  hebephrenia,  organic  dementia, 
acute  sensorial  derangement),  or  by  perversion  or 
parsesthesia  of  the  sense  of  orientation  in  space 
(hallucinatory  insanity,  melancholia   with  religious 


86  ELEMENTS    OF    MENTAL    ALIENATION. 

or  demoniacal  delusions,  secondary  systematized 
insanity,  general  paralysis). 

The  reflexes  have  hardly  been  seriously  studied 
up  to  the  present  time,  excepting  in  general 
paralysis,  and  the  results  are  so  far  contradictory. 
According  to  Bianchi,  there  is  in  the  beginning  an 
exaggeration,  and,  later,  progressive  diminution. 
According  to  Mickle,  exaggeration  is  the  rule  in 
sj^philitic  general  paralj^sis,  as  is  diminution  in  the 
alcoholic  form.  According  to  Bettencourt-Rod- 
riguez,  the  commencement  of  general  paralysis  is 
characterized  by  a  diminution  or  abolition  of  the 
cutaneous  reflexes  and  an  exaggeration  of  the 
tendon  reflexes,  which  combination  fonns  a  useful 
element  in  the  diagnosis.  Besides  we  frequently 
observe  in  general  paralysis,  as  in  tabes,  the 
Argyll- Robertson  symptom  (sensibility  of  the  pupil 
to  accommodation  and  not  to  light)  and  Pitres'  symp- 
toms (diminution  or  absence  of  the  testicular  reflex) . 

Among  the  insane  (properlj?^  so-called)  it  seems, 
according  to  the  essaj'-s  that  have  been  attempted 
in  this  direction,  that,  in  chronic  insanity,  all  tlie 
reflexes,  cutaneous,  sensorial,  and  tendinous,  remain 
usually  normal,  while  they  are  diminished  in 
depressive  conditions  and  increased  in  states  of 
excitement.  We  find  also  in  certain  cases,  notably 
in  melancholia  cum  stupore,  the  existence  of 
paradoxal  reflexes. 

Organic  Sensibility  (internal  sensations). — Or- 
ganic sensibility  includes   all   the   sensations   tliat, 


FUNCTIONAL    ELEMENTS.  87 

conveyed  by  tlie  centripetal  nerves  of  each  organ, 
transmit  to  the  brain  the  impressions  produced  by 
their  functional  activity,  their  needs,  and  their  condi- 
tion of  health  or  disease.  It  is  this,  as  Morselli  states, 
that  gives  us,  in  great  part,  the  collective  or  synthetic 
feeling  of  organic  individuality  (coenaesthesis) .  In 
the  normal  condition  the  organic  sensibility  is  re- 
duced to  rudimentary  sensations  that  arise  in  the 
depth  of  unconsciousness.  But  these  sensations 
may  be  exalted,  disappear,  or  be  perverted,  and  it 
is  principally  among  the  insane  that  we  encounter 
these  alterations. 

Sometimes  the  patients  think  their  organs  cease 
their  functions ;  it  seems  to  them  that  something  is 
lacking  in  their  vital  equilibrium,  that  they  are  unlike 
the  rest  of  the  world,  and  this  is  plainly  the  origin  in 
them  of  the  delusive  conceptions  that  are  so  common  in 
general  paralysis,  cerebral  syphilis,  tabetic  insanity? 
neurasthenia,  and  melancholia,  which  cause  them  to 
say  that  they  have  no  stomach,  heart,  mouth  or  arms, 
that  their  food  does  not  go  down,  that  they  are  choked, 
that  they  feel  ill,  that  they  are  dead.  I  have  many 
times  found  an  absolute  anaesthesia  of  the  digestive 
tract  in  these  cases,  and  oesophageal  catheterism  could 
be  performed  without  producing  the  least  reaction  of 
any  kind. 

At  other  times,  on  the  contrary,  the  sensations  of 
the  organic  activity  are  increased.  The  patients  feel 
then  more  lively  and  active ;  they  experience  a  feel- 
ing of  extraordinary  well-being,   the  more  intense 


88  ELEMENTS    OF    MENTAL    ALIENATION. 

sometimes  since  it  follows  a  condition  of  discomfort 
and  depression.  This  is  what  occurs  in  the  period 
of  excitement  in  circular  insanity,  and  especially  in 
the  period  of  functional  exaltation  of  general  paral- 
ysis, when  the  patients  declare  that ' '  they  never  were 
better,"  just  at  the  moment  when  the  disorganiza- 
tion has  taken  possession  of  their  whole  sj^stem.  We 
must  recognize  doubtless  in  this  state  of  organic 
sensibility,  if  not  the  absolute  cause,  at  least, 
the  point  of  departure  of  those  delusions  of  power, 
of  vigor  and  force,  seen  in  most  cases  of  insanity  of 
the  exalted  type,  especially  in  the  expansive  form  of 
general  paralysis. 

As  to  the  sensations  of  organic  Avants,  they  may 
be  increased,  as  in  mania,  or  abolished,  as  in  melan- 
cholia. This  is  particularly  the  case  with  the  feel- 
ings of  hunger  and  thirst,  hence  the  anorexias  and 
bulimias,  the  polydipsias  and  adipsias  so  common 
in  the  insane. 

The  perversions  of  the  organic  sensibility  are  yet 
more  frequent  and  varied  in  the  patients.  They  may 
develop  in  all  parts  of  the  body  and  from  all  the  vis- 
cera, but  their  seat  of  j)redilection  is  the  abdomen. 
Thus  we  hear  of  strange  feelings  (organs  that  shift 
about,  animals  in  the  stomach  or  belly,  nocturnal  out- 
rages, sudden  pregnancies,  demon  in  the  heart,  etc., 
etc. )  which  give  rise  to  tlie  most  extravagant  dehisions. 
These  perversions  are  connected  usually  with  func- 
tional or  organic  affections  of  the  viscera,  to  which 
we  shall  return  later  on. 


FUNCTIONAL    ELEMENTS.  89 

c. — Dison'ders  of  Motility. 

All  possible  lesions  of  motility  are  observed  in 
conditions  of  mental  alienation.  We  will  examine 
successively  the  anatomical  condition  of  the  muscles, 
the  passive  and  active  attitudes  of  the  body,  the  con- 
tractility to  mechanical  stimulation,  the  electro-mus- 
cular contractility,  the  dynamometric  and  dynamo- 
gra])hic  mensuration,  and  finally  the  functional 
lesions,  properly  so-called. 

The  muscles  are  most  frequently  flaccid  and  re- 
laxed, sometimes  even  atrophied,  either  from  the 
efi^ect  of  inertia  (melancholia,  stupor,  dementia),  or 
from  disorder  of  the  general  nutrition  (marasmus  of 
paralysis,  stupor  and  dementia),  or,  finally,  from  di- 
rect lesion  of  the  nervous  trophic  centres  (paralytic 
dementia) . 

The  spontaneous  attitudes  in  certain  forms  of 
psychoses  are  truly  characteristic.  Sometimes  there 
is  complete  abandon  with  resolution  of  the  whole 
muscular  system,  as  if  a  patient  had  collapsed 
(general  paralysis) ;  sometimes  there  is  a  crouching 
together,  as  if  he  desired  to  occupy  the  least  possible 
space  (melancholiacs,  hallucinated  cases,  dements) ; 
sometimes  again,  there  is  an  absohite  immobility,  a 
complete  default  of  reaction  to  stimulation  and  an 
inert  indifference  to  surroundings  (stupor). 

Among  the  motor  alterations,  allied  to  voluntary 
attitudes  we  should  notice  the  loss  of  equilibrium  in 
the  erect  posture,  the  eyes  being  closed  (Romberg's 
symptom),  which  is  usual  in  tabetic  dementia,  and 


90  ELEMENTS    OF    MENTAL    ALIENATION. 

is  met  with  also  in  paralytic  dementia.  We  can 
also  observe,  in  certain  delusional  neurasthenias, 
astasia-abasia,  noted  by  Charcot  and  his  pupils 
among  neuropathic  cases. 

The  muscular  contractility  induced  by  mechan- 
ical or  thermal  agents  is  either  increased  (stuporous 
and  cataleptiform  melancholia,  hypochondria,  neur- 
asthenia, mania),  or  diminished  (simple  melancholia, 
general  paralysis,  and  dementia).  Most  commonly 
it  remains  normal. 

The  electro-muscular  excitability^  is  found  habit- 
ually increased  in  mania,  melancholia  with  coen aesthe- 
tic hallucinations,  and  simple  lypemania.  In  the  con- 
vulsive forms  of  insanity  and  also  in  general  paralysis, 
we  sometimes  encounter  the  so-called  reaction  of 
convulsibility  (Benedikt).  On  the  contrary,  the 
electro-muscular  excitability  is  decreased,  and  at  last 
abolished,  in  profound  dementia  and  general  paralysis 
accompanied  with  spinal  symptoms.  The  reaction 
of  exhaustion  (Benedikt)  is  met  with  in  many 
paralytics. 

Besides  these  quantitative  alterations  of  the  electric 
excitability,  there  are  also  qualitative  changes,  but 
these  are  very  variable  and  not  yet  well  known. 
Melancholia  with  stupor  ma}^  thus  be  accompanied 
with  a  partial  degenerative  reaction,  consisting  in 
the  anode  closing  reaction  occurring  before  that  the 
cathode  closing.  Also  in  general  paralysis  the 
galvanic  excitability  is  ordinarily  more  diminished 
than   is  the   faradic.     Finally  in  melancholiacs  we 


FimCTIONAL    ELEMENTS.  91 

sometimes  find  a  difference  of  excitability  in  the  two 
sides  of  the  body,  and  when  convulsive  phenomena 
occur,  a  tremulous  contraction  of  the  muscle  during 
the  passage  of  the  galvanic  current  (interpolar 
hyperexcitability) . 

The  force  of  contraction  of  the  different  muscular 
groups  is  not  easily  tested  with  the  dynamometer  in 
the  insane  and  this  method  hardly  serves  to  more 
than  indicate  the  amount  of  volitional  energy  they 
possess  (passive  melancholia,  stupor,  apathetic 
dementia).  The  dynamograph  is  more  useful;  it 
shows  that  the  curve  varies  in  different  mental 
affections  according  to  the  state  of  the  motor  centres 
and  of  the  muscles  (hemiplegic  dementia,  progressive 
general  paralysis,  alcoholic  pseudo-general  paralysis, 
neurasthenia,  etc.). 

Among  the  lesions  of  motility,  properly  so-called, 
observed  in  the  insane  we  may  mention  :  paralysis 
and  paresis,  general  or  partial  (diffuse  cerebro-spinal 
affections,  general  paralysis,  hemiplegic  dementia, 
epileptic  insanity,  acute  febrile  delirium,  idiocy) ; 
spasms  and  cramps  (hypochondria,  acute  mania, 
excited  periods  of  circular  insanity,  spasmodic 
melancholia,  hysteria,  epileps}'^),  among  which  special 
mention  should  be  made  of  the  pharyngeal  spasm  of 
hydrophobic  insanity  and  the  grinding  of  the  teeth 
in  general  paralj^tics;  contractures,  localized  or  in- 
volving all  the  members  (idiocy,  hysteria,  paralytic 
and  hemiplegic  dementia) ;  tremors  and  tremulous- 
uess,  dependent  either  on  a  centi'ul  lesion  (paralytic 


92  ELEMENTS    OF    MENTAL    ALIENATION. 

dementia,  alcoholism,  epilepsy),  or  upon  a  2:)sycliic 
condition  ( anxious  melancholia,  neurasthenia ) ; 
ataxia  or  motor  incoordination,  which  is  observed  in 
all  forms  of  paralysis,  alcoholic  intoxication,  etc., 
sometimes  diffuse,  sometimes  localized ;  convulsions, 
general  or  partial,  with  more  or  less  complete  loss  of 
consciousness  (general  paralysis,  cerebral  syphilis, 
alcoholic  and  saturnine  intoxication,  grave  form  of 
senile  dementia),  with  which  we  should  rank  that 
extraordinary  excitability  of  the  nervous  system  not 
quite  reaching  convulsions,  which  goes  under  the 
name  of  convulsibility  (acute  mania,  anxious  melan- 
cholia, neurasthenic  insanity) ;  tetany  of  the  muscles 
presenting  a  great  analogy  to  convulsibility^  (stupor- 
ous melancholia) ;  catalepsy  and  pseudo-catalepsy 
(hysterical  insanity,  melancholic  ecstasy,  stupidity, 
acute  hallucinatory  conditions),  which  are  usually 
accompanied  by  a  profound  cutaneous  and  muscular 
anaesthesia;  parakinesis,  or  abnormal  distribution 
and  transmission  of  motor  impulsion,  consisting  in 
paradoxical  contractures  and  rigidity  to  movement 
of  the  muscles  (stupidity,  katatonic  melancholia, 
insanity  of  doubt  or  contact) ;  psychic  or  imaginary 
paralysis,  consisting  in  phenomena  of  motor  inhibi- 
tion (hysterical  and  hypochondriacal  insanities, 
abulic  neurasthenias) ;  alteration  of  the  tone  and 
tirabre  of  the  voice,  of  the  movements  of  writing, 
etc.,  which  are  seen  in  certain  insanities  with  intense 
agitation  (acute  mania,  anxious  melancholia,'  general 
paralysis).     According  to  Morselli,  change  of  voice 


FUNCTIONAL    ELEMENTS.  ,     93 

is  sometimes  a  prodromic  symptom  of  chronic 
periencephalitis.  The  same  may  be  the  case  with 
change  of  handwriting. 

Disorders  of  the  Vegetative  Functions. 

Following  Morselli,  we  shall  study  successively 
under  this  head:  the  circulation,  the  respiration, 
nutrition  and  assimilation,  the  secretions,  the  tem- 
perature, and  the  trophic  and  vaso-motor  functions. 

a. — Circulation. 

Affections  of  the  heart  are,  in  a  general  way,  more 
frequent  in  the  insane  than  in  those  of  sound  mind. 
According  to  Dr.  Duncan  Greenlees,  the  proportion 
of  deaths  from  cardiac  disease  are  9.36  per  cent,  in 
the  former,  and  8.72  per  cent,  in  the  latter.  Most 
frequently,  the  heart  disorder  antedated  the  insan- 
ity, and  has  played  an  important  part  in  its  produc- 
tion ;  in  certain  cases,  nevertheless,  it  seems  to  Ije 
the  consequence  of  excessive  agitation,  (mania,  lype- 
mania,  epilepsy.) 

Many  of  the  insane  present  all  the  signs  of  a  pre- 
cocious atheromatous  degeneration;  in  others  we 
find  atrophy,  fatty  degeneration  of  the  heart  or  its 
spontaneous  rupture.  The  disorder  most  commonly 
met  with  is,  according  to  most  authors,  mitral  in- 
sufficiency with  hypertrophy  of  the  left  ventricle. 
Among  functional  disorders  we  find  anaemic  bruits 
de  souffle^  frequency,  feebleness,  and  intermittence 
of  the  cardiac  pulse. 


94  ELEMENTS    OF   MENTAL   ALIENATION. 

En  resume^  in  a  great  number  of  the  insane,  30 
per  cent,  according  to  some  authorities,  75  per  cent, 
according  to  others,  the  useful  action  of  tiie  labor 
of  the  heart  is  diminished  so  that  the  amount  of 
blood  circulating  in  the  organs  is  diminished,  and 
its  distribution  altered. 

The  pulse  does  not  offer  in  insanity  any  character- 
istic alteration  of  quantity  and  quality.  In  a 
general  way,  however,  it  is  frequent  and  high 
in  states  of  excitement,  and  slow  and  feeble  in 
depressive  conditions.  But  this  is  not  an  absolute 
rule  since  in  many  melancholiacs,  and  even  in  stupor, 
it  may  attain  to  ]00  or  120  per  minute.  In  the 
chronic  forms  the  pulse  is  habitually  normal,  except 
in  hallucinated  cases  and  during  periods  of  agitation. 
Rapid  variations,  dicrotism,  and  poly  erotism  are 
very  frequent  in  the  insane. 

Wolf,  who  has  made  numerous  sphygmographic 
researches  on  the  pulse  in  different  psychoses,  lays 
stress  on  the  fact  that  we  meet  more  often  than 
otherwise  with  the  loss  of  the  parallelism,  which 
exists  in  the  normal  condition,  between  the  curve  of 
temperature  and  that  of  the  oscillations  of  the  pulse. 
Morselli  claims,  however,  that  the  later  investiga- 
tions of  Claus  do  not  confirm  Wolf's  results.  Sphyg- 
mograph}^  will  be  of  especial  value,  according  to 
Shaffer,  in  distinguishing  the  different  periods  of 
circular  insanity. 

Greenlees  {Jour.  Ment.  Sci.,  1887)^  draws  from 
his    sphygmographic    observations     the     following 


J'tJKCTlONAL    ELEMENTS.  95 

conclusions:  In  acute  mania  we  find  the  nervous 
centres  congested,  the  arterial  walls  relaxed,  whence 
a  diminution  of  arterial  tension  and  dicrotic  trace  of 
the  pulse.  In  the  chronic  form  the  trace  approaches 
the  normal. 

In  acute  melancholia,  feeble  cardiac  systole, 
incomplete  filling  of  the  arteries.  In  the  chronic 
form  the  pulse  recovers  its  force. 

In  general  paralysis,  pulse  variable  according  to 
the  period.  In  the  first  stage,  systole  energetic, 
arterial  tension  feeble.  In  the  second,  less  energetic 
systole,  arterial  tension  restored.  In  the  third,  sys- 
tole feeble,  but  the  complete  tracing  resembles  that 
of  the  first  stage. 

In  dements  the  tracing  shows  a  torpid  circulation 
due  to  a  weakness  of  the  vaso-motor  system. 

In  imbeciles  there  is  always  increase  of  the 
arterial  tension  and  of  the  systole. 

b.  — Respiration. 

The  examination  of  the  respiration  is  much  less 
significant  in  the  insane  than  that  of  the  circulation. 

We  encounter,  nevertheless,  chronic  diseases  of 
the  chest,  pulmonary  phthisis,  bronchial  catarrh, 
emphysema. 

In  the  maniacs  the  respiration  exhibits  nothing 
special  as  a  rule,  as  regards  its  frequency.  In  the 
melancholiacs  the  respiratory  movements  are  some- 
times shallow  and  very  frequent,  sometimes  slow 
and  deep ;  we  may  also  meet  here  the  inverse  type 


96  ELEMENTS    OF   MENTAL    ALIENATION. 

of  respiration,  i.  e. ,  the  expiration  longer  than  the 
inspiration.  Marce  has  observed  in  these  patients 
an  abnormal  proportion  between  the  number  of 
inspiration  and  cardiac  beats.  This  ratio,  one  to 
four  normally,  becomes  less  in  melancholia  when 
it  may  be  only  one  to  five  or  six  pulsations. 

In  certain  emotional  conditions  the  thoracic  move- 
ments may  be  made  by  jerks  and  recoveries  and 
sometimes  even  with  tremors  and  starts.  In  ad- 
vanced general  paralysis,  especially  during  apoplecti- 
form attacks,  we  see  intermittent,  remittent,  and 
arhythmic  respiration,  as  in  the  Cheyne-Stokes 
phenomenon. 

c. — Nutrition  and  Assimilation. 

The  first  thing  to  do,  in  judging  of  the  state  of 
nutrition  of  an  individual,  is  to  examine  the  ratio  of 
weight  to  stature. 

In  the  prodromic  period  of  many  insanities,  before 
the  mental  disorders  reveals  itself  even,  the  weight 
of  the  body  is  notably  reduced.  In  agitated  states 
and  mania,  there  is  a  general  lack  of  nutrition; 
in  the  apathetic  forms,  on  the  contrary,  the  patients 
may  become  obese.  In  the  intermittent  and  circu- 
lar insanities  regular  changes  of  body  weight  are 
often  observed  in  each  period  of  the  attacks.  In 
the  marasmus  of  melancholia,  mania,  and  general 
paralysis,  emaciation  is  progressive  and  may  reach 
an  excessive  degree.  Finally  at  the  decline  of  the 
acute  attacks,  the    nutrition  is  re-established,  and 


FUNCTIONAL    ELEMENTS.  97 

this  is  a  favorable  symptom  on  condition  it  coin- 
cides with  a  parallel  amelioration  of  the  mental 
condition. 

The  disorders  of  the  digestive  tract  are  very  com- 
mon in  mental  alienation.  We  encounter  particularly : 
cancer,  ulcers,  gastric  dilatation,  dyspepsia,  gas- 
tritis, chronic  peritonitis,  duodenal  catarrh,  cancer 
of  the  rectum,  displacement  of  the  transverse  colon, 
dysentery,  enteritis;  congestion  and  abscess  of  the 
liver,  nephritis,  interstitial  and  parenchymatous ;  ves- 
ical catarrh,  cystitis,  hypertrophy  of  the  prostate, 
etc.,  etc. 

The  functional  troubles  are  not  less  numerous  and 
important.  They  are  saburral  conditions,  fetor  of 
the  breath,  regurgitation  with  pyrosis,  vomiting, 
gastrorrhagias  and  enterorrhagias,  intestinal  colic, 
meteorism;  tympanitis,  constipation  particularly, 
diarrhoea,  and  incontinence  of  urine  and  faeces. 
These  symptoms  may  be  observed  in  all  forms  of 
insanity,  acute  or  chronic,  simple  or  associated,  but 
they  are  more  special  to  melancholic  conditions, 
where  they  are  rarely  lacking.  It  is  to  them  that 
is  due,  in  great  part,  the  sitiophobia,  or  refusal  of 
food,  which  is  not  to  be  confounded  with  lack  of 
desire,  though  this  accompanies  it  in  many  cases. 

d. — Secretions. 

The  salivary  secretion  is  most  often  altered   by 

excess   in    mental    diseases    (ptyalism,    sialorrhoea) . 

The   insane  who  present  the   symptom   may  be 

Ment.  Med.— 7. 


98  ELEMENTS    OF    MENTAL    ALIENATION. 

divided,  according  to  Reinhardt,  into  three  groups : 
(1)  The  imbeciles,  idiots,  dements,  and  paralytics 
in  whom  the  saliva  is  fluid  and  aqueous,  (vaso-motor 
paralysis) ;  (2)  the  cases  of  systematized  insanity 
with  delusions  of  poisoning  and  sitiophobia,  in 
whom  the  saliva,  at  first  very  abundant  and  watery, 
becomes  later  thick  and  turbid  from  fragments  of 
glandular  epithelium  (conscious  reflection  and  mor- 
bid action  of  psychic  centres) ;  (3)  cases  of  mania 
and  circular  insanity,  and  sexually  excited  insane, 
in  whom  the  saliva  is  glassy,  tenacious,  whitish  and 
viscous  (local  mechanical  excitation  or  irritation  of 
the  great  sympathetic). 

In  certain  cases,  as  in  acute  delirium  and  delirium 
tremens,  the  discharge  of  saliva  may  become,  so  to 
speak,  incessant. 

The  gastric  secretion  is  almost  always  disordered 
in  the  dyspepsia  and  sitiophobia  of  the  melancholiacs 
and  delusional  insane,  in  the  polyphagia  of  mania 
and  dementia,  in  the  stomachal  vertigoes  of  hypo- 
chondria and  epilepsy,  in  the  anorexia  of  alcoholism, 
in  the  gastric  dilatation  of  neurasthenia,  etc. ,  etc. 

In  late  years,  chemical  analysis  of  the  gastric  juice, 
obtained  by  the  stomach  tube  during  digestion,  has 
led  to  the  division  of  the  dys2:>epsias  into  several  cate- 
gories: from  excess  of  peptone;  from  dilution  of 
the  gastric  juice;  from  hyperchlorhydria ;  from 
anachlorhydria ;  from  fermentation  (Alb.  Robin). 
The  same  scientific  methods  have  enabled  Carl  v. 
Noorden    (1887)   and   Pachoud   (1888)    to  demon- 


FUIfCTIOlSrAL    ELEMENTS.  99 

strate  that  in  melancholiacs  there  is  generally  accel- 
eration of  digestion  and  hyperacidity  of  the  gastric 
juice,  due  almost  exclusively  to  the  presence  of  free 
hydrochloric  acid. 

There  have  not  yet  been  as  thorough  investiga- 
tions of  the  biliary  secretion  in  the  insane.  We 
know,  nevertheless,  that  there  is  an  excess  of  bile  in 
many  cases  (melancholia,  chronic  insanity,  toxic 
insanity),  and  that  it  gives  rise  either  to  sub-acute 
attacks  oi  jaundice,  or  to  the  more  or  less  unre- 
vealed  formation  of  gall  stones  which  we  find  in 
great  numbers  at  the  autopsy.  The  intestinal 
atony  of  certain  lypemaniacs  and  delusional  insane 
may  also  be  connected  with  insufficient  biliary 
secretion. 

The  perspiration  is  frequently  altered  in  emotional 
conditions,  as  is  well  known,  and  in  diseases  of 
the  spinal  cord.  This  occurs  also  in  the  insane. 
Many  have  a  dryness  of  the  skin,  hair  bristly  and 
dry  owing  to  a  lack  of  secretion  (anidrosis) ;  such 
are  found  among  the  melancholiacs,  the  stuporous 
cases,  and  general  paralytics.  Others,  on  the  con- 
trary, perspire  abundantly  (hyperidrosis) ,  so  that 
their  skin  becomes  sometimes  cold  and  cedematous 
(mania,  emotional  neurasthenia).  The  beginning  of 
certain  mental  diseases  is  marked,  in  some  cases,  by 
the  absence  of  ^perspiration,  or,  on  the  other  hand,  by 
the  appearance  of  local  or  general  sweating  (general 
paralysis,  hypochondriacal  insanity).  I  have  ob- 
served  in  some  diathetic   psychoses,    especially  in 


100  ELEMENTS    OF    MENTAL    ALIENATION. 

artliritism,  a  very  marked  alternation  between  the 
mental  condition  and  the  secretion  of  sweat. 

The  nauseous  odor  of  many  of  the  insane,  which 
has  been  compared  to  that  of  mice,  depends,  accord- 
ing to  Morselli,  upon  the  untidiness  and  the  fetid 
breath  of  the  patients,  rather  than  upon  any  chemi- 
cal modification  of  the  cutaneous  exhalations.  There 
is,  nevertheless,  an  increased  acidity  ordinarily  accom- 
panying the  phases  of  agitation  of  cyclical  insanity. 
Some  idiots  give  out  an  odor  like  musk  (Frigerio) . 

The  sebaceous  secretion  has  been  scarcely  studied 
in  the  insane.  We  know  it,  moreover,  only  very  im- 
perfectly in  the  normal  conditions.  M.  Arnozan, 
according  to  some  experiments  made  in  conjunction 
with  myself,  has  noted  some  peculiarities  in  the 
insane,  without,  however,  attaining  any  precise  data, 
as  yet.  After  much  research  we  have  discovered, 
nevertheless,  the  existence  of  sebaceous  matter,  in 
general  paralytics,  in  regions  where  it  is  not  found 
habitually,  for  example,  in  the  axilla. 

The  study  of  the  blood  finds  its  place  either 
amongst  the  functions  of  nutrition  or  the  trophic 
functions.  We  range  it  here  because  it  is  insepara- 
ble from  that  of  the  urine. 

It  has  been  observed  that  in  most  of  the  insane, 
either  in  the  beginning  or  in  the  course  of  their  dis- 
order, the  number  of  l)lood  globules  is  notably 
diminished  (melancholia,  stupor,  dementia),  and 
that  this  hypoglobuly  is  especially  marked  in  the 
females.     It  has  also  been  observed,   perhaps  even 


INUNCTION AL    ELEMENTS. 


101 


more  frequently,  that  there  is  a  diminution  of  the 
haemoglobin  of  the  blood  (depressive  and  stuporous 
forms).  In  tJie  maniacs,  the  composition  of  the 
blood  aj^proaches  the  normal.  In  no  case  are  the 
proportions  of  the  red  and  white  globules  altered. 

In  a  recent  memoir  (./o7«\  Ment.  Sci.^  Oct.,  1890), 
Dr.  Johnson  Smyth  reports  the  results  of  numerous 
experiments  made  by  him  on  the  blood  of  the  insane. 
We  give  their  summary  in  the  following  table : 


State  of  Health 

Melancholia 

Epilepsy 

General  Paralysis . . . , 
Secondary  Dementia 


HaBmoglobin. 


93.    per  ct. 

69.7  " 

62.8  " 
68.7  "• 
53.7       " 


Red  Globules 
per  cubic  mm. 


5,106,000 
4,684,000 
4,520,800 
4,700,250 
4,070,000 


Specific 
gravity. 


1.056 
1.057 

1.059 
1.060 
1.061 


Whence  it  follows,  very  clearly,  that  in  the  insane, 
there  is,  in  a  general  way,  a  decrease  of  haemoglobin 
and  the  red  globules  of  the  blood,  while,  on  the 
other  hand,  the  specific  weight  of  the  fluid  is  aug- 
mented. It  also  appears  that  the  morbid  species 
in  which  these  peculiarities  are  most  marked  are  in 
decreasing  order:  secondary  dementia,  epileps}^, 
melancholia,  and  general  paralysis.  As  to  the  ratio 
of  white  to  red  corpuscles,  the  author  affirms  that 
he  has  found  no  constant  variation  from  the  normal. 

The  most  important  of  the  secretions  in  the  insane, 
as  it  is  in  the  physiological  condition,  is  that  of  the 
urine.  It  may  be  altered  in  insanity  both  as  to 
quantity  and  quality. 


102 


ELEMENTS    OF   MENTAL   ALIENATION. 


Ill  a  qualitative  point  of  view,  the  alterations  con- 
sist in  modifications  of  tlie  physiological  principles 
and  introduction  of  pathological  ones. 

Urea,  phosphates,  and  chlorides  are  found  some- 
times in  excess  (paralytics  and  maniacs),  sometimes 
below  the  normal  figure  (melancholia,  dementia). 

As  regards  the  elimination  of  phosphoric  acid,  it 
appears  from  the  studies  of  Mendel  and  Mairet  that 
in  mania,  lypemania,  and  excited  periods  of  insanity, 
there  is  an  increase  of  the  phosphates,  especially 
the  earthy  ones,  in  the  urine,  while  in  idiocy  and 
dementia,  in  which  the  general  nutrition  is  retarded, 
there  is  a  decrease  of  these  salts. 

Dr.  Johnson  Smyth,  in  the  memoir  already  cited, 
sums  up  as  follows,  the  composition  of  the  urine  in 
the  different  forms  of  insanity : 


fl  ^  <u 

S  o  ;3 

otal  of  Solids 
per  diem  in 
grams. 

9 

.2 

C  CO 

■3  2 
S^  So 
o 

Chloride  of 

Sodium  in 

grams. 

•a  2 

O  " 

p- 

H 

^ 

0.9 

1.3 

•< 

State  of  Health 

1856.2 

37.8 

28.2 

9. 

1.2 

Melancholia 

1295.8 

38.87 

25.04 

1.8 

1.65 

Epilep.sy 

1520.8 

3G.8 

25.17 

2.1 

2.19 

Secondary  Dementia . 

1408.0 

34.8 

20. 

2. 

2.9 

0.69 

Genei-al  Paralysis  . . . 

1578.0 

47.0 

26.0 

3.1 

3.3 

1.6 

From  this  table  it  appears :  (1)  Tliat  the  quantit}^ 
of  urine  excreted  is  above  the  normal  in  general  par- 
alysis and  epilepsy,  inferioi-  in  melancholia  and  sec- 
ondary   dementia;    (2)    that   the    total  of  solids  is 


FUNCTIONAL   ELEMENTS.  103 

greatly  increased  in  general  paralysis ;  (3)  that  the 
amount  of  urea  is  slightly  in  excess  in  the  psychoses, 
except  in  dementia ;  (4)  that  the  amount  of  uric  acid 
is  notably  above  the  physiological  average,  first, 
in  general  paralysis,  then  in  epilepsy  and  dementia ; 
(5)  that  creatinine  also  is  more  abundant  in  general 
paralysis  and  dementia;  (6)  finally,  that  there  seems 
to  be  a  slight  excess  of  phosphoric  acid  in  epilepsy, 
but  that  this  constituent  differs  very  little  from  the 
normal  in  the  other  disorders. 

Among  the  pathological  elements  of  the  urine, 
sugar  and  albumen  are  the  ones  chiefly  to  be  sought 
for.  Sugar  may  be  found  in  varying  proportion  in 
diabetic  insanity,  acute  delirium,  delirium  tremens, 
chronic  alcoholism,  epilepsy,  general  paralysis,  at 
the  beginning  or  after  the  congestive  attacks. 

Albumen,  according  to  Kappen  (1888),  is  espe- 
cially frequent  in  insanity  connected  with  chronic 
nephritis,  or  arterio-sclerosis,  in  acute  delirium, 
general  paralysis  and  epilepsy.  It  appears  either  in 
its  usual  form,  or  under  the  form  of  propeptone 
(hemlalbumenose  or  paralbumen) .  In  some  cases  of 
so-called  Brightic  insanity  (Dieulafoy,  Raymond,) 
the  mental  condition  follows  exactly  the  fluctuations 
of  the  uraemia. 

Dr.  Marro,  (Neurol.  Gentralhl.^  1888)^  claims  to 
have  constantly  found  peptonuria  in  twenty-one  par- 
alytic dements.  The  amount  of  peptone  was  some- 
times minimal  and  required  as  much  as  800  to  1,000 
cubic  centimetres  of  urine  to  give  Hofmeister's  re- 


104  ELEMENTS    OF    MENTAL    ALIEN ATIOK. 

action.  It  was  greatest  in  cases  that  followed  an 
acute  course  or  were  complicated.  This  author  goes 
so  far  as  to  affirm  that  the  absence  of  peptone  ex- 
cludes the  diagnosis  of  general  paralj^sis. 

The  same  author,  {Arch,  de  JFreniatria,  1889,)  has 
found  acetone  in  marked  quantity  in  the  urine  of 
patients  dying  from  acute  delirium  with  terrifying 
hallucinations.  He  believes  that  the  presence  of 
this  substance  has  to  do  with  the  existence  of  this 
kind  of  hallucinations. 

We  sometimes  find  also  in  the  urine  of  the  insane, 
cylinders,  generally  with  albumen  (acute  conditions) 
mucus,  pus,  epithelial  cells,  leucocytes,  and  even 
blood  (paralytic  dementias).  Finally,  mention  should 
be  made,  as  of  possible  occurrence,  of  azoturia,  urae- 
mia, with  its  convulsive  and  delusive  forms,  ischuria, 
strangury  from  spasm  of  the  neck  of  the  bladder,  or 
paralysis,  retention  and  incontinence,  conscious  or 
unconscious  (Fere) . 

e. — Temperature. 

Insanity  is  almost  always  an  apyretic  disorder, 
which,  in  many  cases,  does  not  affect  the  equilib- 
rium of  the  sources  of  animal  heat  and  is  not  accom- 
panied, save  in  special  phases  and  in  certain  particular 
forms,  with  any  reaction  of  the  organism.  For  this 
reason,  thermometric  investigation  has  in  it  but  a 
limited  application. 

The  general  temperature  may  be  increased  in 
acute  cases  of  insanity,  but  only  in  the  congestive 


I'UNCTIONAL    ELEMENTS.  105 

types  (mania,  epilepsy,  general  parslysis).  The  tem- 
perature is  lowered,  on  the  other  hand,  in  the 
depressed  or  apathetic  forms,  in  marasmus,  and 
melancholia.  We  may  meet  with  extraordinary  ele- 
vations of  temperature  in  certain  stages  of  general 
paralysis.  We  also  may  encounter  an  irregular  dis- 
tribution of  bodily  heat  in  the  peripheral  parts 
(local  asphyxias),  but  these  are  more  of  the  order  of 
vaso-motor  troubles. 

The  cranio-cerebral  temperature  has  been  found 
increased  in  the  exalted  forms,  and  lowered  in  the 
depressive  forms.  There  have  even  been  noted 
notable  differences  between  the  two  halves  of  the 
head  and  the  different  lobes  of  the  brain.  But  it  is 
not  necessary  to  unreservedly  accept  these  results. 

/. — Tropliic  and  Vaso-motor  Functions. 

The  disorders  of  these  functions  are  very  import- 
ant in  psychiatry.  We  will  notice  among  the 
trophic  disorders : 

(1)  Alterations  of  the  skin,  either  in  the  distri- 
bution of  pigment,  or  abnormal  pigmentations,  or  in 
the  nutrition  of  the  different  tegumentary  layers. 
Sometimes  we  encounter  true  dermatoses,  such  as 
eczema,  zona,  herpes,  ichthyosis,  phthiriasis,  endemic 
myxcedema,  at  otlier  times  the  skin  exhibits  the 
symptoms  of  a  general  intoxication  of  the  organism, 
as  in  alcoholism  and  pellagra. 

(2)  Difficult  cicatrization  of  wounds,  eschars  of 
wounds  and  bedsores,  tnal  perforant,  spontaneous 


106  ELEMENTS    OF   MENTAL   ALIENATION. 

shedding  of  nails  and  teeth,    othaematoma,  lesions 
due,  for  the  most  part,  to  peripheral  neuritis. 

(3)  Fragility  of  the  bones,  trophic  arthropathies, 
especially  in  the  chondro- sternal  articulations. 

(4)  Muscular  atrophies  and  degenerations,  which 
attain  a  very  high  degree  of  development  in  the 
paralytic  forms  of  insanity,  marasmus  of  dementia, 
and  melancholic  cachexia. 

(5)  Keuro-trophic  keratitis,  diminution  of  lachry- 
mal secretion,  and  finally  fatty  degeneration  of 
various  organs. 

Among  vaso-motor  disorders,  we  find  in  the  insane 
vaso-motor  paralysis  of  the  limbs  or  of  certain  regions 
of  the  skin,  causing  cj^anosis  and  oedema  (stuporous 
and  apathetic  forms  of  melancholia,  circular  insanity 
(Ritti),  dementia);  so-called  local  asphyxias  from 
spasmodic  contraction  of  the  capillaries;  irregular- 
ities in  the  blood-supply  of  parts;  subjective  sen- 
sations of  heat,  cold,  formication,  shivering,  angio- 
paralytic  and  angio-kinetic  phenomena,  localized, 
and,  so  to  say,  alternating  (cyclic  and  periodic  forms 
and  raptiis  melancholicus) .  We  may  find  also, 
under  the  influence  of  light  mechanical  or  electrical 
irritations,  partial  persistent  flusliings,  and  some- 
times also  the  symptom  known  by  the  name  of  the 
vaso-motor  alphabet  (dermograpliy). 

Finally,  we  may  mention  praecordial  pain,  so  im- 
portant in  certain  forms  (melancholia,  epilepsy,  hypo- 
chondria, lij'^steria,  alcoholism,  neurasthenia),  which 
is  a  soil  of  painful  sense  of  constriction  and  gives 


FUNCTIONAL    ELEMENTS.  107 

rise  to  delusive  conceptions  of  the  most  widely  dif- 
fering kinds.  It  is  rarely  lacking  in  the  initial 
melancholic  stage  of  insanity. 

g. — Appendix. 

Action  of  Disorders  of  the  Vegetative 
Functions  on  Insanity:  Sympathy. — Theories 
OF  Bouchard, 

It  is  evident,  from  the  rather  imperfect  enumer- 
ation that  has  been  made,  that  insanity  is  frequently 
connected  with  physical  disorders  and  that  none  of  the 
bodily  organs  escape  these  alterations.  This  is  why, 
from  all  time,  there  has  existed  a  tendencj^  to  consider 
certain  mental  diseases  as  the  immediate  or  remote 
effect  of  a  pathological  change  of  the  viscera,  or  the 
humors  of  the  body.  Hence  the  names,  melancholia, 
hypochondria,  phrenitis,  derived  from  the  supposed 
origins  of  the  various  known  forms  of  insanity. 
Melancholia,  indeed,  has  always  been  especially 
attributed  to  a  functional  or  organic  alteration  of 
the  abdominal  organs,  and  Coelius  Aurelianus  wrote, 
in  Roman  times,  "In  melancholicis  stomachus^  in 
furiosis  vero  caput  afficitur." 

The  theories  advanced  to  explain  this  influence  of 
the  disordered  viscera  on  the  brain,  are  those  that 
have  accorded  with  the  successive  epochs  and  con- 
ditions. One  of  them,  the  most  ancient,  perhaps, 
since  it  dates  from  Hippocrates  and  Galen,  is  the 
theory  of  sympathy,  which,  in  modified  form,  has 
survived  to  the  present  time. 


108  ELEMENTS    OF    MENTAL    ALIENATION. 

It  is  to  be  stated,  however,  that  the  present  time 
is  a  critical  phase  of  this  question  and  that  the 
ancient  idea  of  this  morbid  sjaiipathy  is  giving  way 
to  a  new  conception,  more  in  accord  with  modern 
scientific  notions,  that  of  mito-mtoxication. 

The  admirable  memoirs  of  Bouchard,  on  the  dis- 
orders produced  in  the  organism  by  the  exaggera- 
ted formation  or  retention  of  normal  poisons  in  the 
system,  and  in  particular  those  which  appear  in  the 
digestive  canal  and  the  urine,  are  well  known. 
Admitting  now  the  existence  of  the  gastro-intestinal 
symptoms  that  accompany  most  acute  forms  of 
insanity,  especially  melancholia,  and  also  admitting 
the  good  effects  obtained  by  washing  out  the 
stomach,  not  merely  on  the  melancholiac  sitioj^hobia, 
but  also  on  the  lypemania  itself,  it  is  perfectlj^ 
logical  to  assume  that  in  many  of  these  cases  the 
insanity  is  the  result  of  an  auto-intoxication. 

Some  papers  have  already  been  published  support- 
ing this  jjathogenic  view.  I  will  cite  especiallj^  the 
communication  of  M.  Bettencourt-Rodriguez,  to 
the  International  Congress  of  Mental  Medicine 
(1889),  on  "The  influence  of  the  phenomena  of 
auto-intoxication  and  of  dilatation  of  tlie  stomacli 
in  the  depressive  and  melancholic  forms ; "  the  thesis 
of  Chardon,  inspired  by  Prof.  Lcmoine,  on  "The 
influence  of  infectious  diseases  on  tlie  development 
of  mental  disorders"  (Lille,  1889-90),  and  that  of 
Feyal  on  "Constipation  in  the  insane"  (Lyons, 
1890).     I  will  mention   finally  the  opening  lecture 


FUNCTIONAL    ELEMENTS.  109 

of  my  free  course  at  Bordeaux  (1889-90) :  ' '  Insanity 
and  the  auto-intoxications;  "  and  especially  the  ex- 
cellent thesis  of  one  of  my  pupils,  Dr.  Chevalier- 
Lavaure  who,  analyzing  the  toxic  power  of  the 
urine  of  the  acutely  insane,  according  to  Bouchard's 
method,  has  been  able  to  demonstrate  that,  in  these 
conditions  and  especially  in  mania,  the  urine  loses  a 
large  proportion  of  its  toxicity,  undoubtedly  from 
the  morbid  retention  of  normal  poisons.  While  an 
average  of  25  cubic  centimetres  of  normal  daily 
urine  and  35  cubic  centimetres  of  healthy  night 
urine  are  required  per  kilogram  to  kill  an  animal, 
60  cubic  centimetres  of  maniacal  day  urine  and  69 
of  night  urine,  are  required  to  produce  the  same 
eifect.  In  one  case  all  the  urine  passed  in  a  day 
was  insufficient  to  destroy  a  rabbit  experimented 
upon  [Des  auto -intoxications^  dans  les  maladies 
nie^itales.  Bordeaux,  July,  1890).  These  results 
are  comparable  to  those  obtained  by  M.  Fere,  on 
the  urine  of  ej^ileptics,  recognized  as  more  toxic 
before  than  after  a  convulsive  attack. 

Attention  has  hardly  been  given  to  other  than  the 
auto-intoxications  alone,  in  the  insane,  and  especially 
those  that  have,  for  their  point  of  departure,  the 
digestive  tract  and  its  annexes.  The  theories  of 
Bouchard,  however,  in  regard  to  general  disorders 
from  retardation  of  nutrition  seem  to  me  equally 
applicable  to  the  pathogeny  of  certain  so-called 
diathetic  forms  of  insanity,  particularly  those  some- 
times engendered  by  arthritism.     This  is  the  opinion 


110  ELEMENTS    OF    MENTAL    ALIENATION. 

of  Prof.  Pierret  (International  Congress,  1889)  and 
of  M.  Charj^entier,  who,  besides  general  paralysis 
from  congestion,  admits  the  existence  of  another 
group  of  general  paralyses  from  intoxication,  in 
which  he  ranks  those  due  to  gout,  diabetes,  arthrit- 
ism,  and  overalimentation  {An?i.  3fed.  Psychol.^ 
Oct.,  1890).  For  my  part  I  have  observed  one  very 
clear  case  of  hereditary  arthritic  insanity  with  uric 
retention,  anidrosis,  and  manifold  trophic  disorders, 
in  which  the  insanity,  incontestably  due  to  the 
eifects  of  retarded  nutrition,  constantly  followed  the 
oscillations  of  the  diathetic  intoxication. 

It  will  be  seen  what  a  horizon  is  opened  for  the 
future  in  psychiatry  by  the  theories  and  methods  of 
the  present  day.  We  may,  it  is  true,  expect  that 
the  permissible  limits  of  deduction  will  be  soon 
passed,  as  is  always  the  case,  and  that  some 
adventurous  spirits  will  go,  doubtless,  to  the  extent 
of  making  all  insanity  the  result  of  the  poisoning  of 
the  organism,  of  an  intoxication.  Some  positive 
data  however  will  be  gained,  and  the  discoveries  of 
chemical  biology,  more  fruitful  in  this  direction  than 
histology,  will  necessarily  lead  to  some  progress  in 
the  treatment  of  nervous  diseases.  We  have  already 
seen  that  experimental  analysis  of  the- gastric  juice 
has  enabled  Van  Noorden  and  Pachoud  to  determine 
the  existence  of  gastric  hyperchlorohydria,  in 
melancholia  and  consequently  to  recommend  the 
use  of  alkalies.  A  still  more  minute  analysis  of 
this  liquid,   according  to  recent   methods    (Gaston 


COI^STITUTIONAL  OK  ORGANIC  ELEMENTS.        Ill 

Lyon :  L'' Analyse  dti  sue  gastrique^  sa  technique^ 
ses  cqyplications  cUniques  et  the7'apeittiq'ues^  These 
de  Paris,  1890),  gives  us  without  question  the  data 
for  a  rational  treatment  of  melancholiac  dyspepsias, 
or  we  may  say  the  dyspeptic  lypemanias,  and, 
especially,  for  transforming  the  present  lavage  of  the 
stomach  into  a  rational  therapeutic  method,  scien- 
tifically based  upon  the  condition  of  the  gastric 
juice  and  the  organs  of  digestion.  The  same  results 
will  follow  thorough  study  of  the  blood,  and  of  the 
urine,  and,  in  various  degrees,  that  of  other  excre- 
tions, such  as  the  perspiration,  the  saliva,  and  the 
sebaceous  secretion.     X  (1) 


§11.     CONSTITUTIONAL  OR  ORGANIC  ELEMENTS. 

These  elements  are  divided  into  the  lesions  of 
organization  or  of  evolution^  and  lesions  of  disor- 
ganization or  of  involution,  according  as  they  attack 
the  individual  during  the  time  of  his  development 
or  after  it  has  been  completed. 

Lesions  of  Organization. 

The  lesions  of  organization  characterize  more 
especially  a  group  of.  mental  diseases  which  we  shall 
consider  later  under  the  name  of  degeneracies  of 
evolution  or  vices  of  psychic  organization.  But  we 
may  encounter  them,  more  or  less  isolated,  in  a 
large    number    of    the    insane.     They    consist   in 


v 


112  ELEMENTS    OF    MENTAL    ALIENATION. 

deviations,  excesses,  or  arrests  of  development, 
which  involve  not  only  the  cerebral  functions,  but 
also  all  the  apparatuses  or  organs  of  the  economy. 
We  will  pass  them  rapidly  in  review  under  the 
denominations  of  psychical  stigmata  and  physical 
stigmata. 

a. — Psycliic  Stigmata. 

The  law  that  controls  the  teratological  alterations 
of  the  intelligence  is,  in  opposition  to  the  normal, 
the  discordance  or  defect  of  equilibrium.  It  follows 
that  the  essential  characteristic  of  the  psychic 
anomalies,  is,  before  everything  else,  a  lack  of  pro- 
portion between  certain  undeveloped  faculties  and 
others  normal  or  in  excess. 

In  the  intellectual  spheres,  proj^erly  speaking,  it 
is  the  higher  faculties,  the  judgment,  the  mental 
consecutiveness,  the  attention,  and  the  will,  that  are 
defective,  while  the  other  mental  powers,  on  the 
other  hand,  such  as  memory,  imagination,  inven- 
tion, the  power  of  expression,  or  the  various  artistic 
aptitudes,  may  be  very  well  developed. 

In  the  moral  or  emotional  sphere,  the  arrest  of 
development  aif ects  particularly  as  a  rule,  the  loftier 
sentiments  and  the  higher  affections,  while,  on  the 
contrary,  there  is  often  a  veritable  hypertrophy  of 
the  passions  and  the  lower  feelings  and  instincts. 
The  ensenthle  of  this  condition,  as  it  appears  in  some 
degenerated  cases,  is  commonly  known  under  the 
name  of  absence  of  the  moral  sense. 


CONSTITUTIONAL  OE  ORGANIC  ELEMENTS.        113 

h. — Physical  Stigmata. 

The  stature  is  often  abnormal  in  insanity,  especi- 
ally in  the  degeneracies  and  the  monstrosities.  We 
may  meet  with  dwarfishness  or  with  excessive 
stature,  eifeminacy,  and  various  deformities  of  the 
spine  and  thorax. 

In  the  limbs  we  may  find  paralyses,  contractures, 
tics,  hypertrophies,  and  partial  or  general  atrophies. 
The  extremities  are  sometimes  characteristic;  there 
may  be  syndactylism,  polydactylism,  club  feet,  flat- 
footedness,  and  what  has  been  called  the  idiot  hand 
(long  and  slender  with  defective  development  of  the 
thumb). 

The  cranium  exhibits  numerous  deformities.  Its 
volume  is  generally  above  the  normal.  From  a  com- 
parison of  475  skulls  of  the  insane  and  212  others, 
Seppilli  obtained  the  following  averages:  insane 
males,  1,544  c.  c,  other  males,  1,474  c.  c. ;  insane 
females,  1,341c.  c. ,  other  females,  1,316  c.  c.  The 
form  is  very  variable.  Together  with  orthocephaly 
we  encounter  microcephaly,  megalocephaly,  brachy- 
cephaly,  (eurycephaly  and  acrocephaly),  dolicho- 
cephaly  (scaj^hocephaly  and  plagiocephaly) ,  and 
general  or  partial  asymmetry.  Next  follow  liyper- 
trophy  and  atrophy  of  the  walls,  persistence  of 
fontanelles  and  sutures  or  their  premature  ossifica- 
tion, exostoses,  flattened  spots,  wormian  bones,  etc., 
etc. 

The  face  also  shows  asymmetry,  deformities  of  the 
|)alatine  vault,    which   may  be   narrow,   deep  and 

Ment.  Med.— 8. 


114  ELEMENTS    OF   MENTAL   ALIEN ATIOlf. 

ogival,  deviation  of  tlie  nasal  septum,  promin- 
ence of  the  zygomas,  protuberance  of  the  frontal 
sinuses,  fullness  and  separation  of  the  orbital  cavi- 
ties, prognathism,  simple  or  double,  prominence  and 
heaviness  of  the  jaw,  etc.,  etc. 

Dr.  Cuylitz  claims  that  degeneracy  is  controlled 
by  one  law,  i.  e.,  the  vitiation  of  the  proportions 
between  diameters.  This  being  so,  anthropological 
science,  as  applied  to  the  study  of  mental  aliena- 
tion, is  especially  a  science  of  indices.  According 
to  him  it  matters  little  whether  the  brain  has  more 
expansion  in  one  way  or  the  other,  or  equally  in  all 
directions,  i.  e.,  whether  the  individual  be  dolicho- 
cephalic, brachy  cephalic,  or  orthocephalic.  The 
essential  thing  is  that  the  organ  is  not  hindered  in  its 
development  by  any  isolated  resistance,  since,  in 
that  case,  it  undergoes  a  settling  which  shows  itself 
externally  by  a  deformity  of  the  palatine  vault. 

"For  a  long  time"  says  M.  Cuylitz  (unpublished 
communication)  "  it  has  been  recognized  that  an 
ogival,  narrow,  and  deep  palatine  vault  is  an  index 
sign  of  mental  inferiority.  The  phenomenon  can 
be  explained  as  follows :  The  brain  tends  to  develop 
transversely,  but,  it  meets  in  some  cases  a 
resistance  in  the  parietal  region  which  crowds  it 
back.  This  pressure  is  transmitted  by  the 
zygomatic  temporal  and  molar  processes,  pushes 
together  the  alveolar  bodies  of  the  superior  maxil- 
laries,  like  a  workman's  tongs,  the  separation  of  the 
main  branches  of  which,  that  is  of  the  parietals. 


CONSTITUTIONAL  OR  ORGANIC  ELEMENTS.        115 

brings  the  ends  together,  the  hinge  being  repre- 
sented by  the  body  of  the  sphenoid  and  the  occipital. 
The  bringing  together  of  the  alveolar  bodies  or  the 
ogival  palate,  is  therefore  only  the  expression  of  a 
cerebral  collapse,  an  abnormal  eifort  which  in  the 
psychic  life  reveals  itself  by  degeneracy.  There  is 
normally  a  proportion  of  one  to  three  and  a  half 
between  the  distance  from  each  other  of  the  alveo- 
lar margins  at  the  horizon  of  the  last  uj^per  molars 
and  the  parietal  or  maximum  transverse  diameter  of 
the  skull.  In  the  hereditary  degenerate,  and  there- 
fore mentally  imperfect,  the  intermolar  distance  and 
the  interparietal  diameter,  are  as  1  'A^  or  5,  and 
in  the  idiot  as  even  1:6  or  6.8.  This  proportion  or 
index  is  therefore,  as  regards  the  anthropology  of 
the  insane,  of  an  extreme  importance,  which  has 
not  up  to  the  present  been  recognized." 

The  alterations  of  the  encephalon  are  very 
common  in  the  insane.  The  meninges  are  frequently 
thickened,  adherent  to  the  cranial  walls  or  to  the 
cortex,  contain  osseous  corpuscles,  and  scattered 
here  and  there  deposits  or  cysts  of    serous  matter. 

In  the  brain  we  find  general  or  partial  hypertro- 
phy or  atrophy,  absence  of  some  convolutions  or 
presence  of  sujoplementary  ones,  widening  of 
grooves  and  fissures,  and  anomalies  of  different 
regions,  particularly  the  psychomotor,  the  fissure  of 
Sylvius,  the  calcarine  fissure,  the  external  perpendic- 
ular, the  Rolandic  and  the  frontal  furrows. 

As  regards  its  weight,  we  find  in  the  simple  acute 


116  ELEMENTS    OF    MENTAL    ALIENATION. 

insanity  a  brain  larger  than  the  normal,  and  in  the 
chronic  forms  an  atrophy,  more  or  less  pronounced, 
as  is  also  the  case  in  idocy  and  imbecility.  Nothing, 
moreover,  is  more  variable  than  the  brain  weight  in 
the  insane,  not  only  in  general,  but  also  in  the 
different  forms.  It  may  range  in  the  pure'  insanities 
from  1,200  to  1,580  grams  ;*in  dementia,  from  986 
to  1,580  grams;  in  imbecility  from  1,040  to  1,575 
grams;  and  in  idiocy  from  566  to  1,710. 

Many  authors  have  remarked  that,  contrary  to  the 
normal  rule,  the  right  hemisphere  often  outweighs 
the  left  in  the  insane. 

The  cerebellum,  pons,  and  cranial  nerves  present 
morphological  changes  much  less  frequently. 

The  lesions  of  the  structure  of  the  mass  of  the 
brain  vary  according  to  tlie  disorder.  We  will  only 
cite  here,  among  the  more  frequent,  hydrocephaly, 
porencephaly,  induration  or  softening,  sclerosis  and 
degenerations  of  all  kinds,  affecting  the  vessels,  the 
neuroglia,  and  tlie  nervous  elements. 

On  the  part  of  the  e3'^es  and  vision  we  note,  blind- 
ness, myopia,  hypermetropia,  astigmatism,  con- 
centric contraction  of  tlie  visual  field,  daltonism, 
hemeralopia,  pigmentary  retinitis,  albinism,  epi- 
canthus,  microphtlialmia,  exophthalmus,  coloboma 
of  the  choroid  and  iris,  chromatic  asymmetry  of  the 
iris  (fitigmafMirien  of  Fere),  strabismus,  nystagmus, 
ptosis,  alterations  of  tlie  papilla,  deformities  and 
inequality  of  the  jjupil,  etc.,  etc. 

The  anomalies  of  the  cars  and  hearing  are  quite 


CONSTITUTIONAL  OR  ORGANIC  ELEMENTS.        117 

frequent  and  important,  and  they  are  justly  consid- 
ered as  true  stigmata  of  degeneracy.  They  have 
been  specially  studied  of  late  years  by  Giacchi,  Fere, 
Lannois,  and  Frigerio.  Besides  complete  or  unilat- 
eral deafness,  which  is  sometimes  hereditary,  and 
otitis  of  every  kind,  we  find  in  the  insane,  ears  badly 
implanted,  asymmetrical,  enormous  or  rudimentary, 
flat,  fleshy,  pointed,  (satyr  ears  of  Schwalbe) ,  widened 
(en  anse)  or  flat  against  the  skull.  We  find  also  par- 
tial deformities,  absence  of  the  tragus  or  antitragus, 
arrest  of  development  or  absence  of  the  helix  and 
antihelix,  prolongation  of  the  root  of  the  helix, 
which,  joining  the  antihelix,  divides  the  concha  into 
two  parts,  (Fere)  the  smoothing  and  rolling  out  of 
the  pavilion,  the  adherence  or  absence  of  the  lobule, 
(Morel's  ear)  the  persistence  of  the  tubercle  of  Dar- 
win, the  anomalies  of  the  scaphoid  fossette,  which 
may  be  lacking,  be  single,  double  or  triple,  and  con- 
tinue itself  in  the  lobule  even  independently  of  the 
inversion  of  the  antitragus,  etc. ,  etc.  According  to 
Fere,  the  morphological  alterations  occur  more  com- 
monly on  the  left  side. 

Frigerio,  who  has  employed  a  special  instrument 
in  the  anthropological  study  of  the  external  ear 
(Arch.  crAnthrop.  Cririiinelle^  icS'^^',)  notices  further 
the  following  peculiarities :  (1)  The  auricular  tem- 
poral angle  (ecartement  de  V  oreille),  which  is  under 
90  degrees  in  sane  individuals,  and  only  reaches  this 
figure  in  20  out  of  100,  tends  to  increase  in  the  insane 
individuals,  where  we  find  39  per  100  with  it  90  de- 


118  ELEMENTS    OF    MENTAL    ALIENATION. 

grees,  and  in  criminals  in  whom  it  is  found  in  55  out 
of  a  hundred,  and  in  apes  where  the  angle  is  generally 
over  100  degrees.  (2)  The  average  index  of  the 
concha  for  the  two  ears  is  greater  in  the  insane  than 
in  the  normal  individual,  while  that  of  the  pavilion 
is  inferior.  Nevertheless,  in  the  insane,  the  concha 
is  more  developed  than  the  pavilion,  especially  in 
the  transverse  sense. 

In  the  mouth  and  teeth  we  find :  congenital  divi- 
sion of  the  palate,  of  the  uvula,  hare  lip,  niegalo- 
glossus,  persistence  of  first  dentition,  absence  or 
duplication  of  certain  teeth,  their  smallness  (micro- 
dentism)  or  their  exaggeration  {(jeantis7n)^  tubercles, 
notches,  caries,  anomalies  of  direction,  especially  of 
canines  and  incisors,  the  presence  of  grooves,  de- 
formities of  the  dental  arch,  etc.,  etc.  (Bourneville 
and  Sollier). 

In  the  genital  organs,  likewise  well  studied  by 
Bourneville  and  Sollier,  (1888),  we  find  in  males: 
hernia,  rudimentary  condition  or  exaggerated  size  of 
the  penis,  club  shaped  penis,  phymosis,  ej^ispadias, 
hypospadias  with  three  varieties,  balanic,  pelvic  and 
scrotal,  anorchidia,  monorchidia,  cryptorchidia,  atro- 
phy and  asymmetry  of  the  testicles,  varicocele,  scar- 
city or  absence  of  spermatozoa,  impuberty,  gyneco- 
mastia (Emile  Laurent).  In  the  female,  narrowness, 
imperf oration  or  transverse  or  longitudinal  partition 
of  the  vagina,  absence  of  the  ovaries  and  tubes,  es- 
pecially of  one  side,  uterus  bicornis,  polymastia, 
amenorrhcea,  etc, 


CONSTITUTIONAL  OK  ORGANIC  ELEMENTS.        119 

As  regards  the  skin,  we  will  confine  ourselves  to 
mentioning  albinism,  vitiligo,  pigmentary  ngevi, 
erectile  naevi,  icthyosis,  myxcedema,  scarcity  or 
abundance  of  hair,  beard  or  mustache  in  women, 
tufts  of  hair,  and  double  vortex,  trace  of  anomalous 
development  of  the  cephalic  extremity  of  the  verte- 
bral canal  (Fere). 

Finally,  we  note,  as  to  the  larynx  and  voice,  the 
hypertrophy  or  absence  of  the  thyroid  body,  mutism, 
persistence  of  the  infantile  voice,  and  of  various  vices 
of  pronunciation,  stammering,  repetition  or  convul- 
sive suspension  of  certain  syllables,  stuttering, thick- 
ness of  speech,  zezaiement  (giving  g  or  j  the  sound 
ofz). 

Lesions  of  Disorganization. 

Lesions  of  disorganization  are  especially  charac- 
teristic of  a  group  of  mental  disorders  that  we  shall 
study  later  or  under  the  name  of  degeneracies  of  in- 
volution or  psychic  disorganizations.  They  consist 
essentially  in  acquired  infirmities,  ^.  e. ,  in  the  decay 
of  the  psycho-physical  being,  and,  like  the  lesions 
of  organization,  they  may  affect  not  only  the  cere- 
bral functions  but  all  the  apparatus  and  organs  of 
the  economy. 

It  seems  needless  to  enter  into  detail  and  enumerate 
here  these  lesions,  as  they  are  all  noticed  under  spe- 
cial pathology.  It  may  be  said  merely,  that  those 
most  frequently  met  with  in  the  psychic  sphere  are : 
weakness  of  memory  for  recent  events,  ideas,  and 


120  ELEMENTS    OF    MENTAL    ALIENATION. 

words  (intellectual  and  verbal  amnesia),  loss  of  vol- 
untary attention  {2)ol(/ideisme),  obnubilation  of  af- 
fections, feelings,  habits  of  education,  etc. ,  etc. ,  Avith 
more  or  less  marked  persistence  of  automatic  intel- 
ligence and  instincts. 

In  the  physical  organization  the  decay  may  involve 
all  parts.  It  affects  especially  the  nervous  centres, 
the  muscular  functions,  the  organs  of  sense,  the  gen- 
ital instinct,  and  the  excretions. 


Chapter  IFIFIT* 

CLASSIFICATION. 

The  importance  of  classification  in  any  science 
whatever  is  self-evident.  In  mental  pathology  it  is 
an  absolutely  essential  guide. 

It  has  therefore  been  attempted  by  a  great  num- 
ber of  authors,  from  ancient  times  to  the  present, 
and  apropos  to  this  it  has  been  maliciously  remarked 
by  Buchez,  "When  they  think  they  have  finished 
their  studies,  the  rhetoricians  construct  a  tragedy 
and  the  alienists  a  classification." 

All  classifications  proposed  up  to  the  present  may 
be  classed  under  four  chief  heads :  (1)  psychological 
classification,  based  on  the  nature  of  the  intellect- 
ual disorders  (Ex.  Hammond's,  of  New  York) ; 
(2)  symptomatic,  based  upon  the  outward  manifes- 
tations of  the  disease  (Ex.  Esquirol,  Marce) :  (3)  path- 
ogenic or  etiological,  based  on  the  causes  and  origin 
of  development  of  the  insanity  (Ex.  Morel) ;  (4)  an- 
atomical, based  on  the  character  of  the  lesions  (Ex. 
Voisin,  Luys). 

The  majority  of  classifications  are  mixed  rather 
than  truly  systematic,  that  is  to  say,  they  are  con- 
structed at  once  on  several  of  the  lines  above 
enumerated. 

I  will  confine  myself  here  to  reproducing  simply 


122  CLASSIFICATION. 

and  without  comment,  the  cLassifications  of  MM. 
BaiUarger,  Ball,  and  Magnan  for  France:  that  of 
Hack-Tuke  and  Bucknill  in  England,  and  that  of 
Krafft-Ebing  in  Germany,  and  finally  the  nomen- 
clature adopted  by  the  International  Congress  of 
Mental  Medicine  (1889)  from  the  report  of  M.  Morel 
of  Gand,  and  which  is  merely  designed  to  furnish 
alienists  of  all  countries  with  a  series  of  denomina- 
tions or  rubrics  under  which  they  can  hereafter  ar- 
range their  clinical  cases  so  as  to  make  them  readily 
comparable. 

Classification  of  M.  Baillarger. 

The  Insanities.  The  Dementias. 

Functional  Perversions.  Functional  Abolitions. 

1.—Insa7iities. 

I.    Pure  Insanities.  f  Partial  insanity. 

Such  as,  when  not  cured,  J  Mania, 
terminate  most  frequently  1  Melancholia, 
in  simple  dementia.  I  Double  form. 

II.    Paralytic  Insanities.  f 

Such  as,  when  not  cured,  J  Ambitious  mania. 

terminate  most  frequently  1  Hypochondriacal  melancholia. 

in  paralytic  dementia.  I 

{Simple    intermittent     insanity. 
Insanity      with    alternating 
forms . 

IV.     Circular  Insanities \  ^''^gSSty!'''"     '^''''^^''     ^'''""'    "'" 

{Alcoholic  insanity. 
Pellafjrous  insanity. 
Insanity  of  malarial  origin. 

VI.   Insanities  associated  with  van-  J  Epileptic  insanity. 
ous  neuroses I  Hysterical  insanity. 

W.— Dementias. 

I.    General  Paralysis  idhnenceparalytique). 
II.    Senile  Dementia. 

III.  Dementia,    symptomatic    of    various    circumscribed    cerebral 

disorders. 

IV.  Dementia  following  vesauias. 

III.— Arrests  of  Development. 
Idiocy,  Imbecility,  Mental  Debility,  Cretinism. 


CLASSIFICATION. 


123 


Classification  of  Phofessor  Ball. 

1.  Vesanic  or  essential  (without  lesion).    Types :    Cir- 
cular insanity,  systematized  insanity. 

( Hysterical. 

2.  Nearopathic •<  Epileptic. 

( Choreic,  etc. 


3.  DiafJietic 


(  Gouty. 

Kheumatic. 
i  Tuberculous. 

Cancerous. 

Anfemic,  etc. 


r  Genital. 

Insanities.  -I  4.  Sympathetic gJstroSntestinal. 

t  Pulmonary,  etc. 

I  Alcoholic. 

5.  Toxic <  Saturnine. 

{ Morphine,  etc. 

r  General  paralysis. 

6.  Orcfaiiic    or     cerebro-   \  Aphasia. 
spinal 1  Acute  delirium. 

I  Hemiplegic  dementia,  etc. 


GoimnUca  or  morpho-  i  J^S^Jinty. 
^^^^'^^'^ Cretinism. 


Classification  of  M.  Magnan. 

1.— Mixed  States,  both  pathological  and  mental. 

General  paralysis. 

Senile  dementia  (cerebral  atheroma). 

Circumscribed  cerebral  lesions,  aphasia  for  j  Tr°„,^!',!15.'  ^ 
pxamnlp  \  Hemorrhage, 

example |  Tumors,  etc. 

Hysteria. 

Epilepsy. 

r  Absinthe. 

I  Morphine  and  opium. 
Alcoholism  and  intoxication -{  Vei-digris. 

j  Brgot. 

[Lead,  etc. 

II. — Insanities  properly  so-called.    Psychoses. 

S£choiia;::::::::::::::::::::::::::::::::hi"^pi^«i«^«'^t«- 

f  Incubation. 

Chronic  lu^uilty ^  StS""' 

(^  Dementi^. 


124  CLASSIFICATION. 

r  Simple. 
Intermittent  Insanity ^  Double  form. 

(.Alternate. 
Insanity  of  degenerates,  with  episodic  syndromes,  and  the  delires 

(femblee  (primary). 
Idiots,  imbeciles,  weaklings,  ill-balanced  individuals. 


Classification  of  Hack  Tuke. 

l.—Protopathic  Insanity. 
Idiocy. 

Hemiplegic  dementia. 
General  paralysis. 
Epileptic  insanity. 
Senile  and  idio-functional  insanities. 

U.—Deuteropathic  Insanity. 

Insanity  of  puberty. 
Uterine  insanity. 
Climacteric  insanity. 
Puerperal  insanity. 
Kheumatismal  insanity. 
Syphilitic  insanity. 

HI.— Toxic  Insanity. 
Alcoholism. 
Pellagrous  insanity,  etc.  / 


Classification  of  Krafft-Ebing. 

A. — Psycldc  Affections  of  the  Normally  JDeveloj^ed  Brain. 
1 .  —PsycJw-neuroses. 

\  ■iw<^io»,..v.^vH..    (  Simple  melancholia. 
Melanchoha  )  MelanchoUa  with  stupor. 

.    X.  •                    1.1                 -M-oni-o  J  Maniacal  exaltation. 

1.  Primary  curable  con-  J  Mama 1  Acute  mania. 

Stupor  or  curable  dementia. 

I  "Wahnsinn"  vesania,  properly  so-called, 
i         apart  from  mania  and  melancholia. 

a.  Secondary  Insanity  (Verrucktheit). 

3,  Dementia  (terminal)  (with  agitation  or  with  aphasia). 


CLASSIFICATION.  125 

II. — Psychic  Degeneracies. 

1.  Reasoning  insanity. 

2.  Moral  insanity. 

3.  Primitive  insanity  (primdre  j  Witli  delusions  of  persecution. 

VerrUcWieil) \  Witli  erotic  or  religious  delusions. 

4.  Obsessions. 

f  Epileptic  insanity. 

5.  Insanity  due  to  constitutional  I  Hysterical  insanity. 

neuroses 1  Hypochondriacal  insanity. 

t  Periodical  insanity. 

HI. —Cerebral  Msmxlers  loith  predominant  mental  troubles. 

1.  Paralytic  dementia. 

2.  Cerebral  syphilis. 

3.  Chronic  alcoholism. 

4.  Senile  dementia. 

5.  Acute  delirium. 

B. — Arrests  of  Development. 
Idiocy. 
Cretinism. 


International  Nomenclature. 

Adopted  by  the  Congress  of  Pans  (1889). 

1.  Mania  (acute  deliinum). 

2.  Melancholia.  ^ 

3.  Periodical  insanity  (cii'cular  insanity,  etc.) 

4.  Progressive  systematized  insanity. 

5.  Vesanic  dementia. 
G.  Organic  dementia. 

7.  Paralytic  insanity. 

8.  Neurotic  insanity  (hypochondria,  hysteria,  epilepsy,  etc.) 

9.  Toxic  insanity. 

10.  Moral  and  impulsive  insanity. 

11.  Idiocy. 

I  come  now  to  my  own  classification,  which  is  the 
same,  except  for  successive  variations  produced  by 
the  progress  of  the  times,  as  the  methodic  arrange- 
ment I  liave  many  times  reported,  and  especially  in 
the  earlier  edition  of  this  work. 


126  cliASsiFicATio:^f. . 

Ill  constructing  it  I  aimed  at  two  principal 
ends:  (1)  to  group  the  morbid  forms  according  to 
tlieir  most  important  nosological  cliaracters,  in  sucli 
a  way  as  to  obtain  rational  and  methodical  divisions ; 
(2)  to  retain  only  the  absolutely  primary  forms,  and 
to  rank  apart  those  secondary  states  that  encumber 
most  classifications,  so  as  to  have  the  classification 
at  once  simple  and  complete. 

First,  I  will  state  how  I  proceed  to  obtain  the 
first  of  these  results. 


I. 


The  intelligence,  considered  as  a  biological  entity, 
presents  itself  to  us  under  two  aspects:  (1)  its  con- 
stitution^ that  is  to  say,  its  composition,  its  intimate 
structure ;  (2)  its  functions,  that  is,  its  life  properly 
speaking,  its  mode  of  action.  In  other  words,  we 
may  consider  in  it,  as  with  all  tlie  great  vital  appara- 
tuses,, the  organ  and  the  function.  But  the  diseases 
of  the  intelligence  differ  essentially  according  as  the 
lesion  involves  one  or  the  other  of  these  elements,  and 
it  is  in  this,  in  my  judgment,  that  is  to  be  found 
the  fundamental  division  of  conditions  of  mental 
disease. 

We  will  divide,  therefore,  these  states  into  two 
great  classes:  (1)  functional  or  dynamic  alienations 
(vesanias,  insanities,  psychoses) ;  and  (2)  constitu- 
tional or  organic  alienations  (degeneracies,  devia- 
tions,  mental  infirmities).     Tlie   first  represent,    so 


CLASSIFICATIOiSr.  127 

to  sj^eak,  the  diseases  of  quality,  the  second  those 
of    quantity  of    the  intelligence. 

This  first  landmark  fixed,  we  pursue  our  study 
with  this  dichotomous  division  of  these  two  classes 
of  mental  alienation. 

Insanity,  as  follows  from  what  has  been  said,  is  a 
state  of  mental  alienation  characterized  especially 
by  a  functional  alteration  of  the  intelligence.  But 
this  disease  is  not  a  single  one :  it  forms  a  class 
including  many  distinct  groups  which  it  is  import- 
ant to  specify. 

From  all  time  it  has  been  customary  to  divide 
insanities  into  general  and  partial  according  to  the 
greater  or  less  extension  of  the  delirium.  Thus 
we  have  general  mental  aberrations  (mania,  melan- 
cholia) and  partial  ones  (monomanias).  This  is, 
moreover,  the  basis  of  the  well  known  classification 
of  Esquirol.  The  idea  was  certainly  good,  but  its 
application  is  bad,  since  mental  aberration  is  not 
insanity,  it  is  only  one  of  its  elements,  and  the 
terms  general  deliriums,  partial  deliriums,  do  not 
correspond  to  the  terms  general  and  partial  insanity. 
Moreover,  these  are  genuine  insanities  without 
mental  aberration,  and  it  is  not  uncommon  to  see 
generalized  insanities  with  only  a  partial  delirium 
and,  inversely,  partial  insanities  presenting  very 
extensive  delusions  (megalomania). 

It  is  not,  therefore,  the  degree  of  extension  of  the 
mental  aberration  that  should  serve  as  a  basis  for  the 
division  of  insanities  into  general  and  partial ;  this 


128  CLASSIFICATION. 

basis  is  better  sought  in  the  principal  characters  of 
the  insanity  itself. 

What  are  these  characters  ? 

In  a  biological  point  of  view,  the  insane  fall  into 
two  very  distinct  classes.  In  the  one,  the  whole 
being  takes  part  in  the  disorder  by  reason  of  the 
permanent  reaction  of  the  mental  trouble  on  the 
whole  organism :  there  is,  we  say,  a  lesion  of  general 
activity.  In  the  others,  the  disorder  remains  limited 
to  the  psychic  sphere,  without  seriously  modifying 
ordinary  vital  phenomena,  which  continue  in  a 
regular  and,  as  it  were,  an  independent  manner  : 
the  general  activity  is  unaffected. 

It  is  from  this  point  of  view  that  we  can,  in  my 
opinion,  consider  insanity  as  general  or  partial  :  we 
would  not  call  it  complete  and  inco'mplete — insanity 
is  always  complete  and  irreducible  so  far  as  it  is  a 
disease — but  rather  generalized  from  involvement  of 
the  whole  being,  or,  on  the  contrary,  specialized  to 
the  intellectual  sphere,  its  proper  domain. 

I  retain  therefore  as  primary  divisions  of  conditions 
of  mental  disease  :  (1)  generalized  insanities;  (2) 
partial  insanities. 

Generalized  Insanity. — It  follows  from  what 
has  been  said  that  the  generalized  insanities  arc 
those  in  which  the  general  activity,  which  we  have 
considered  as  the  total  of  the  reactions  of  the  organ- 
ism under  the  influence  of  psycliic  impressions,  is 
found  to  bo  altered.  But  this  alteration  may  take 
place,  as  we  have  stated,  in  two  ways  :  by  excess  or 


CLASSIFICATION.  129 

by  default.  In  the  first  case  there  is  excitation ;  in 
the  second,  depression. 

This  excitation  and  this  depression,  which  consti- 
tute the  two  modes  of  alteration  of  the  general 
activity,  'characterize  also  very  correctly  the  two 
kinds  of  generalized  insanity,  which  are  :  (1)  mania 
(generalized  insanity  with  excitement) ;  (2)  melan- 
cholia or  lypemania  (generalized  insanity  with  de- 
pression). Most  authorities  admit  a  third  species, 
which  may  be  considered  as  the  union  of  the  two 
preceding  ones  :  (3)  insanity  of  double  form  or 
alternating  insanity  (generalized  insanity  with 
successive  excitement  and  depression).* 

In  closing  the  subject  of  generalized  insanities  I 
will  state  that  the  two  species  mania  and  melancholia 
subdivide  into  a  number  of  parallel  or  corresponding 
varieties.  We  have  according  to  the  intensity  of 
the  disease;  (1)  maniacal  excitation  or  subacute 
mania,  which  has  its  pendant  in  melancholic  depres- 

*  Other  authorities  consider  insanity  of  double  fonii,  and, 
in  a  genera]  way,  all  the  periodical  insanities,  not  as  morbid 
entities,  but  simply  as  manifestations  of  the  mental  con- 
dition in  degenerative  cases.  This  opinion  does  not  seem 
to  have  yet  sufficient  basis  in  the  present  state  of  our  knowl- 
edge, to  authorize  its  acceptance  in  my  classification. 
Whenever  it  prevails,  that  is  to  sa}^  when  it  is  proven  that 
the  clement  of  degeneracy  predominates  in  the  so-called 
double  form  insanity  and  in  the  other  periodical  insanities, 
it  will  be  easy  to  take  them  from  the  group  of  generalized 
insanities  and  to  put  them  in  the  degenerative  phrenopathies 
(Table  V  of  classification), 

Ment.  Med. — 9. 


1 30  CLASSIFICATION. 

sion  or  subacute  melancholia;  (2)  acute  mania  or 
typical  mania,  corresponding  to  acute,  or  typical 
melancholia ;  (3)  acute  delirium,  or  superacute  mania, 
which  is  the  extreme  form,  often  febrile  and  mortal, 
of  mania,  like  melancholia  with  stupor  or  si^peracute 
melancholia,  the  highest  development,  hardly  less 
grave,  of  melancholia.  In  the  point  of  view  of 
progress,  we  have  also  as  special  types,  (4)  chronic 
mania  and  melancholia ;  and  (5)  remittent  and  inter- 
mittent mania  and  melancholia. 

As  to  insanity  of  double  form,  the  attacks  of 
which  consist  essentially  in  a  period  of  excitement 
or  mania  and  one  of  depression  or  melancholia,  it 
includes  only  two  species :  (1)  the  continued  insan- 
ity of  double  form,  or  circular  insanity,  in  which 
the  attacks  follow  each  other  without  interrup- 
tion; and  (2)  insanity  of  double  form  with  sep- 
arate or  intermittent  attacks,  in  which  the  attacks 
are  separated  by  a  longer  or  shorter  lucid  interval. 

We  come  now  to  the  division  of  the  partial 
insanities. 

Partial  Insanities. — The  theory  of  partial  men- 
tal aberration  or  monomanias  has  had  for  a  long 
time  a  bad  influence  on  the  progress  of  mental  med- 
icine. Starting  from  the  jjrinciple  that  all  insanities, 
all  the  aberrations,  all  abnormal  tendencies,  how- 
ever isolated,  represent  distinct  entities,  we  have 
come  to  admit  as  many  partial  insanities  or  mono- 
manias as  there  are  morbid  manifestations  in  the 
spheres   of   ideation,  feeling,  or  acts.     Hence  the 


CLASSIFICATION.  131 

division  of  monomanias  into  intellectual,  moral  or 
reasoning,  and  impulsive  or  instructive.  Hence  also 
a  regular  invasion  of  so-called  special  insanities  into 
the  nosological  lists.  Ambitious  delusions  become 
megalomania ;  religious  delusions,  theomania ;  erotic 
insanity,  erotomania;  impulse  to  theft,  kleptomania; 
impulse  to  drink,  dipsomania,  etc.,  etc.  The  iield 
of  monomanias  is  unlimited  and  the  discoveries  pain- 
fully acquired  in  the  past,  are  threatened  with  being 
swept  away  by  this  torrent  of  new  diseases.  Falret, 
Sr.,  was  the  first  to  lift  his  voice  against  this  evil 
tendency  which  was  likewise  combated  by  his  suc- 
cessors, and  to-day,  thanks  esj^ecially  to  the  labors 
of  Magnan,  Morel,  and  many  other  French  and 
foreign  alienists,  the  great  majority  of  the  mono- 
manias, and,  in  particular,  the  reasoning  and  impul- 
sive monomanias,  have  been  relegated  to  their 
proper  place  and  are  considered  as  only  more  or  less 
striking  episodes  of  the  condition  of  degeneracy. 
There  only  remain,  under  the  name,  itself  inexact,  of 
partial  insanities,  a  few  of  the  old  intellectual  mono- 
manias: hypochondriacal  insanity,  persecutory 
insanity,  ambitious,  religious,  erotic,  insanities,  etc. 
Further,  some  of  these  insanities  have  been  subjected 
to  a  synthesis  that  combines  them,  in  an  evolution- 
ary point  of  view,  under  the  same  pathological 
formula. 

According  to  many  authorities,  the  partial  insan- 
ities recognized  at  the  present  time  may  be  com- 
prehended in   a   single   general  type  which,   in  its 


132  CLASSIFICATION. 

normal  form,  presents  a  tj^pical  evolution  in  three 
periods :  (1)  a  period  of  subjective  analysis,  (hypo- 
chondriacal insanity) ;  (2)  a  period  of  delusional 
interpretation  (persecutory,  religious,  erotic,  jealous, 
insanities) ;  (3)  a  period  of  transformation  of  the 
personality  (ambitious  delusions).  We  will  call  it, 
on  these  grounds,  systematized  progressive  insanity. "^^ 
(Chronic  delirium.  Primary  systematized  insanity. 
Paranoia  primaria.      Primare  Verriicktheit.) 

Such  is  the  division  of  the  functional  alienations 
or  insanities  that  appears  to  me  most  rational  and 
most  in  accordance  with  clinical  teachings.  We 
must  now  take  up  the  constitutional  alienations, 
i.  6.,  the  degeneracies,  deviations,  and  mental 
infirmities. 

Constitutional  Alienations  or  Degeneracies. 

The  second  class  of  states  of  mental  alienations 
comprises,  as  has  been  said,  the  constitutional  insan- 
ities or  degeneracies.  They  represent  the  alter- 
ations of  the  intelligence,  in  an  organic  and,  so  to 
say,  quantitative  point  of  view. 

The  intellect,  however,  from  this  point  of  view, 
can  be  injured  in  only  two  ways:  either  it  was 
affected  in  the  time  of  its  evolution,  experiencing 

*  To  those  who  do  not  admit  this  theoretic  conception, 
partial  insanity  is  not  a  disease  of  periods  or  stages,  but 
one  of  varieties.  The  simple  substitution  of  the  word 
"variety"  for  the  word  "stage"  in  our  synoptical  table 
will  therefore  answer  all  their  requirements. 


CLASSIFICATION.  133 

then  a  deviation  or  arrest  of  development ;  or,  having 
attained  its  complete  development,  it  has  undergone 
a  regressive  evolution  or  process  of  decay.  There 
are,  therefore,  two  groups  of  .constitutional  alien- 
ations: (1)  degeneracies  of  evolution  or  vices  of 
psychic  organization  ;  (2)  degeneracies  of  involution, 
or  psychic  disorganizations.  We  will  study  these 
groups  in  detail. 

Degeneracies  of  Evolution  (Vices  of  Organ- 
ization),— Vices  of  psychic  organization  are  com- 
posed of  anomalies  and  malformations  of  the 
intelligence,  altogether  comparable  to  bodily  anom- 
alies and  malformations,  with  which  they  frequently 
coexist,  being,  like  them,  the  habitual  product  of 
hereditary  degeneracy. 

These  anomalies  and  malformations  are,  it  is  true, 
infinitely  variable,  and  thus  elude  any  rigorous  sub- 
division; but,  viewed  in  their  total,  they  exhibit, 
none  the  less,  a  progressive  scale  of  mental  de- 
ficiencies, susceptible  of  being  classed  according  to 
an  ascending  scale  of  gravity. 

At  the  first  step  of  the  ladder,  imperfecth^  separa- 
ted from  the  normal  by  undecisive  limits,  like  every- 
thing appertaining  to  this  neutral  or  borderland 
zone,  we  find  the  defects  of  cerebral  equilibrium 
which  have  for  their  basis  a  lack  of  unity  in  the  ps}''- 
chic  organization,  and  for  a  predominant  character, 
a  morbid  instability.  These  are  indeed  not  jet  act- 
ual diseases ;  but  they  are  already  deviations  of  struct- 
ure, anomalies  of  origin,  that,  as  such,  deserve  to  be 


134  CLASSIFICATION. 

ranked  at  the  threshold  of  the  constitutional  alien- 
ations, under  the  general  title  of  disharmonies. 

At  the  highest  degree  we  encounter  the  mental 
inlirmities,  properly  so  called,  which  reveal  them- 
selves by  arrests  of  development  and  profound  lacu- 
nae of  the  intelligence,  most  commonly  associated 
with  analogous  phj^sical  lesions  forming  thus  the 
most  serious  morphological  alterations  compatible 
with  life.  We  designate  these  under  the  name  of 
monstrosities. 

Between  these  two  conditions,  marking  the  extreme 
limits  of  cerebral  anomalies,  exist  a  crowd  of  inter- 
mediate states  in  which  the  vice  of  organization  is 
usually  connected  with  neuro-  and  psychopathic  dis- 
orders of  the  most  varied  kinds.  Hence  the  morbid 
syndromes  of  dubious  identity,  classed  by  some  in 
the  neuroses  and  monomanias,  and  considered  by 
others  under  the  names  of  the  mental  states  of  the  he- 
r  edit  air  es^  episodic  syndromes  or  psychic  stigmata  of 
heredity,  insanity  of  the  heredltaires,  or  degenerates, 
primary  and  degenerative  paranoia,  etc. ,  as  veritable 
degeneracies  in  which  the  ground  defect  is  the  chief 
element,  the  neuropathic  or  phrenopathic  element 
being  an  accessory  and  f)urely  episodic  element.  This 
view,  which  conforms  best  with  the  general  results  of 
clinical  observation,  seems  the  best  to  adopt  in  the 
present  state  of  our  knowledge, recognizing,  neverthe- 
less, that  in  certain  cases  the  same  neuropathic  and 
phrenopathic  disorders  may  occur  without  any  hered- 
ity or  degeneracy,  properly  speaking.    We  admit. 


CLASSIFICATION.  135 

therefore,  with  certain  reservations,  in  the  constitu- 
tional alienations,  two  intermediate  genera,  the  neu- 
rasthenias and  the  phrenastheiiias^  according  to  the 
nature  of  the  syndrome  present. 

We  have  therefore  the  four  following  genera,  in 
the  order  of  their  gravity :  (1)  the  disharmonies, 
(2)  the  neurasthenias,  (3)  the  phrenasthenias ;  and 
(4)  the  monstrosities. 

These  four  genera  include  in  their  turn  many 
species  and  clinical  varieties. 

In  the  first,  we  can  admit  as  common  types  of 
disharmonies  with  their  diverse  individual  physiog- 
nomies :  lack  of  balance^  originality  or  singnlarity ^ 
and  eccentricity. 

In  the  second  the  varieties  are  much  more  numer- 
ous, at  least  in  appearance.  It  is  easy  to  see,  indeed, 
from  the  table  of  M.  Magnan,  how  the  cerebral  neu- 
rasthenias have  so  recently  become  so  important. 
There  are  still  many  other  forms  possible  to  be  met 
with,  since  it  is  sufficient  to  create  a  new  species,  to 
simply  take  the  predominant  tendency  or  idea  in  a 
neurasthenic,  to  give  it  a  name  and  attach  to  it  the 
termination  "phobia"  or  "  mania,"  according  to  the 
case.  This  is,  in  fact,  what  has  been  done  as  regards 
the  mpst  of  those  already  made.  Instead  of  follow- 
ing this  cult  of  the  infinitely  little,  that  can  have  no 
other  result  than  to  mislead  and  uselessly  complicate 
the  study  of  psychic  degeneracies  already  sufficiently 
difficult,  I  think  it  better,  for  my  part,  to  attempt 
to  point  out,  in  an  accessible  order,  the  specific  types 


136  CLASSIFICATION. 

around  which  all  possible  varieties  and  sub-varieties 
can  gradually  be  arranged. 

But  in  studying  closely  what  we  have  called  the 
neurasthenias  of  deo-eneracv,  it  is  seen  that  they  are 
clinically  species  of  hysteriform  conditions,  with  par- 
oxysmal crises  sometimes  preceded  by  auras,  whicli 
are  based  on  a  lesion  of  the  will  or,  to  speak  physio- 
logically, a  tendency,  more  or  less  pronounced,  to  re- 
flex acts  b}^  excitation  or  inhibition.  We  should 
search  then  for  the  principle  of  their  division,  and, 
proceeding  thus,  we  have  only  to  extend  to  the  total 
of  these  conditions,  that  which  Magnau,  Morselli, 
and  Ribot  have  attempted  to  do  for  some  of  them. 
In  doing  this,  we  find  that  the  lesion  of  the  will  in 
the  neurasthenias  may  present  itself  under  three  as- 
pects, constituting,  so  to  speak,  three  successive  de- 
grees. In  one  the  morbid  suggestions  remain  local- 
ized, in  the  perceptive  sphere.  An  idea  or  group  of 
ideas,  generally  under  the  form  of  interrogations,  or 
metaphysical  apprehensions,  imposes  itself  upon  an 
individual  who  is  forced  to  painfully  chase  them 
away  or  resolve  them.  It  is  a  species  of  "psycho- 
logical rumination  "  as  remarks  Le  Grand  du  Saulle, 
apropos  to  the  '•'•  folie  du  doxite^^^  a  mental  anxiety 
from  Avhich  the  will  tries  in  vain  to  free  itself,  but 
which  is  rarely  accompanied  with  any  irresistible 
tendency. 

These  are  the  psychic  or  ideative  neurasthenias 
{paranoia^  rudin  tent  aria  ideativa,  of  Morselli), 
which  include  all  the  episodic  syndromes,  known  or 


CLASSIFICATION.  137 

unknown,  essentially  characterized  by  fixed  ideas. 
In  a  second  type,  the  conflict  between  the  suggest- 
tion  and  the  will  does  not  remain  a  purely  ideative 
phenomenon ;  there  is  a  tendency  to  action,  to  the 
impulsive  repetition  of  a  word,  a  gesture,  a  ridicu- 
lous  or  unreasonable  act,  and  it  is  the  strife  with 
this  besetting  tendency  that  causes  again  an  anxious 
revolt    of    the  will.     These    are   the  psycho-motor 
neurasthenias  (conscious  impulsions :  paranoia  rudi- 
mentaria  hnpulswa  of  Morselli)  including  all  the 
morbid  syndromes,  known  or  unknown,  essentially 
characterized  by  an  impulsive  besetment  anxiouslj^ 
combated  by  the  will.     Fhially,  in  a  degree  more 
marked,  the  will  is  so  enfeebled  that  its  potential  en- 
erg}^  no  longer  exists  and  the  distress  of  the  individual 
is  not  because  he  is  fatally  urged  to  the  act  but,  on  the 
other  hand,  from  an  agonizing  feeling  of  his  inabil- 
ity to  accomplish  it.     These  cases  are  the  aboulic 
neurasthenias  (aboulias)  the  psychological  condition 
of  which  has  been  very  well  elucidated  by  Theodore 
Ribot  in  his  remarkable  work  on  ' '  The  Diseases  of 
the  Will,"   but  the  clinical  description  of  which  is 
still  to  be  given.     They  comprise   all   the   episodic 
syndromes,  known  or  unknown,  essentially  charac- 
terized by  the  al)olition  of  power  with  persistence  of 
desire,  a    genuine    phenomenon    of    arrest    and  in- 
hibition. 

Psychic,  psycho-motor,  and  aboulic  neurasthenias, 
i.  c,  fixed  ideas,  impulsions,  and  aboulias,  are,  there- 
fore, in  my  opinion,  the  subdivisions  to  be  recog- 


138  CLASSIFICATION. 

iiized  in  the  neurastheuia  of  degeneracy,  the  different 
varieties  of  which  may  moreover,  coexist  or  replace 
each  other  in  the  same  individual.  In  regard  to  the 
phrenasthenias  I  have  also  thought  best  to  make  a 
sort  of  synthesis,  and,  instead  of  enumerating  suc- 
cessively all  the  varieties,  that  is  to  say,  the  numer- 
ous manifestations  of  degenerative  insanity,  I  have 
aimed  to  unite  them  all  under  three  principal  heads 
as  they  present  themselves:  (1)  under  the  delirious 
or  hallucinatory  type ;  (2)  the  lucid  or  reasoning; 
and  (3)  the  impulsive  or  instinctive  form. 

As  to  the  group  of  monstrosities,  its  varieties: 
imbecility,  idiocy,  and  cretinism,  are  admitted  by 
all,  and  I  am  compelled,  like  Morselli,  to  exclude  the 
form  "mental  weakness,"  an  indehnite  type  which 
at  its  extremes  is  confused  with  imbecility,  and  in 
its  lighter  forms  with  the  phrenasthenias. 

Summing  up,  the  degeneracies  of  evolution  or  vices 
of  psychic  organization  divide  up,  according  to  my 
views,  into  four  principal  genera,  which  are,  going 
from  the  simijle  to  the  complex :  (1)  the  disharmonies ; 
(2)  the  neurasthenias;  (3)  the  phrenasthenias;  (4) 
the  monstrosities.  Each  of  these  genera  includes  in 
its  turn,  as  species :  (1)  the  disharmonies :  defect  of 
balance,  originality,  eccenti'icity ;  (2)  the  neuras- 
thenias: fixed  ideas,  impulsions,  aboulias;  (3)  the 
phrenasthenias:  the  delusional,  reasoning,  and  in- 
stinctive, [)hrenasthenia8 ;  (4)  tlie  monstrosities:  im- 
becility, idiocy,  and  cretinism,  to  which  may  be 
added  myxcedema. 


CLASSIFICATION. 


139 


I. — Functional  Alienations  (Insanities,  Vesanias, 
Psychoses.) 


Subacute  mania  (maniacal 

excitation). 
Acute      mania       (typical 

mania). 
(1)  Mania -'  Hyperacute  mania  (acute 

delirium). 
Chronic  mania. 
Remittent  or  intermittoit 
I.     mania. 
Subacute    me  1  a  uc  h  o  1  i  a 

(melancholic  depression . ) 
Acute  melancholia  (typical 

melancholia). 
Hyperacute     melancholia 

(melancholia     with 

stupor). 
Chronic  melancholia. 
Remittent  or  intermittent 

melancholia. 


Generalized 
symptomatic 
sanities 


OB 
IN- 


(2)  Melancholia     or 
lypeinania. 


Partial  or  essen- 
tial INSANITIES. 


(3)  Insanity     of 
double  foini. 


Systematized     jiro- 
gressive  insanity. 


f  Continuous     insanity     of 
I      double  form. 
I  Intermittent    insanity    of 
I      double  form. 


First  stage  (hypochondria- 
cal insanity.) 

Second  stage  (persecutory, 
rel  igio  us,  politic  a  1, 
erotic,  etc.  insanity.) 

Third  Stage  (ambitious 
insanity). 


II. — Constitutional  Alienations  (Degeneracies, 

VIATIONS,    MENTAIy    InFIRMITIES). 


De 


Degeneracies  of 
EVOLUTION  (^n<'es 
of  organization.) 


MsJiarmonies  . 
Neurasthenias. 


Phrenasihenias. 


I 


Monstrosities . 


Degeneracies     op  ( 
Involution  (Dis--,  Dementias. 
organization.)       ( 


j  Defect      of     equilibrium, 
'(    •  originality,  eccentricity. 

j  Fixed    ideas,    impulsions. 
/      aboulias. 

f  Delusional  (multiple  delu- 
I      sions  of  degenerates). 
j  Reasoning   (reasoning   in- 
"i      sanity,  moral  insanity). 
Instinctive  (instinctive  in- 
sanity). 

Tml)ocility. 

Idiocy. 

Cretinism,  myxcedema. 

Simple  dementia. 


140  CLASSIFICATION. 

We  pass  now  to  the  degeneracies  of  involution  or 
psychic   disorganization. 

Degeneracies  of  Ina^olution  or  Psychic  Disor- 
ganization.— AVhile  the  vices  of  organization  form  a 
vast  total  of  morbid  states,  the  grouping  of  which,  as 
we  have  seen,  offers  numerous  difficulties,  the  psychic 
disorganizations  present  themselves  under  a  simpler 
form,  and  without  any  complexity.  Being  essen- 
tially based  on  cerebral  enfeeblement,  that  is  to  say, 
on  the  decadence  of  the  individual,  they  sum  up  in 
a  single  genus,  the  dementias.  It  is  true,  all  the 
cases  of  dementia  are  not  absolutely  alike,  but  they 
have  all  a  common  fundamental  characteristic,  the 
progressive  dissociation  of  tlie  faculties,  in  an  almost 
unvarying  order.  For  this  reason  we  may  have  in 
an  etiological,  not  clinical,  sense  many  kinds  of  de- 
mentias ;  there  is  in  realit}'^  only  one  type,  that  of 
simple  dementia. 

We  have  now  reached  the  end  of  our  classifica- 
tion, in  whicli  we  have  attempted,  as  we  proposed 
to  ourselves,  "to  group  the  mor]>id  forms  according 
to  their  more  imjiortant  nosological  characters,  in 
such  a  way  as  to  obtain  rational  and  methodical  di- 
visions." The  exyjosition  may  have  seemed  some- 
wliat  arid  and  diffuse, — that  is  difficult  to  prevent  in 
such  a  matter', — but  the  total  of  the  preceding  state- 
ments will  not  fail,  we  think,  to  make  it  clear  with 
the  aid  of  the  table  o])posite,  which  gives  in  a  syn- 
thetic list  the  natural  grouping  of  classes,  groups, 
genera,  species,  and  varieties,  that  we  have  adopted. 


CLASSIFICATION.  141 

III. 

Our  classification  stated,  that  is,  the  first  part  of 
the  problem  solved,  we  begin  upon  the  second,  which 
we  have,  it  will  be  remembered,  formulated  as  fol- 
lows :  To  retain  in  this  classification  only  absolutely 
primary  conditions  and  to  rank  apait  the  secondary 
states  which  uselessly  encumber  most  classifications. 

Nothing  is  easier  than  to  realize  this  desideratum 
clinically. 

If  we  go  actually  to  the  bottom  of  things  we  per- 
ceive that  the  innumerable  insanities  existing,  apart 
from  the  primary  types  defined  and  named  above, 
can  all  be  reasonably  considered  as  morbid  associa- 
tions, composed  of  two  elements:  (1)  a  vesanic 
element  represented  by  any  variety  whatever  of 
primary  alienation  (usually  mania  or  melancholia), 
always  identical  fundamentally  with  itself;  (2)  a 
physiological  or  pathological  element  that  serves,  so 
to  speak,  as  a  substratum  and  varies  according  to 
the  case. 

Thus  puerperal  insanity  is  nothing  but  the  asso- 
ciation of  a  mania  or  melancholia  with  the  puerperal 
condition;  uterine  insanity  the  association  of  this 
mania  or  melancholia  with  a  disease  of  the  uterus ; 
paralytic  insanity  its  association  with  general  paral- 
ysis, etc.,  etc.  That  which  differs  in  these  morbid 
associations  is  therefore  not  the  insanity,  which  is 
always  the  same  thing,  but  onlj'-  the  existing  process, 
and  its  proof  is  that  with  information  and  testimony 


142  CLASSrFICATIOIT. 

it  is  impossible  to  distinguish  the  different  composite 
insanities  from  one  another. 

To  close  the  case,  the  symptomatic  insanities  are 
not  special  forms  and  if  they  present  any  more  or 
less  striking  peculiarities  by  reason  of  the  condition 
with  which  they  are  connected,  they  do  not  essentially 
differ  from  simple  insanity,  of  which  they  may  rightly 
be  considered  as  combinations. 

This  view,  exact  and  practical,  has  the  further 
merit  of  simplifying  the  general  conception  of 
mental  disorders,  since  it  shows  that  alienation 
is  at  bottom  reducible  to  a  few  primary  types  and 
that  all  the  other  insanities  are  nothing  but  an 
association  of  these  types,  invariably  playing 
the  role  of  a  radical,  with  some  organic  process  or 
other. 

In  this  way  we  believe  we  have  solved  the  second 
term  of  the  problem,  in  striking  out  from  our  class- 
ification "  all  the  secondary  conditions  which  encum- 
ber the  majority  of  classifications." 

If  now  we  take  a  general  view  of  the  route  by 
which  we  have  come,  we  perceive  that  the  data  which 
have  been  given  may  be  summed  up  in  the  following 
formulas : 

I.  The  conditions  of  mental  alienation  are  sus- 
ceptible of  being  divided  into  two  great  classes: 
(1)  functional  alienations  or  insanities ;  (2)  constitu- 
tional alienations  or  degeneracies. 

The  insanities  subdivide  into  two  groups  :  (1) 
generalized   insanities;    (2)   partial   insanities.     The 


CLASSIFICATION.  143 

generalized  insanities  comprise  in  their  turn  three 
genera:  (1)  mania,  (species:  subacute,  acute,  hyper- 
acute, chronic,  remittent,  and  intermittent  mania) ; 

(2)  melancholia,  (species:  subacute,  acute,  hj^per- 
acute,  chronic,  remittent,  and  intermittent  melan- 
cholia.) (3)  Insanity  of  double  form  (species: 
continuous  and  intermittent  double  form  insanities.) 
The  partial  insanities  have  only  one  genus ;  system- 
atized progressive  insanity,  composed  of  three  stages 
or  species:  (1)  hypochondriacal  insanity ;  (2)  persecu- 
tory, religious,  political,  erotic,  jealous,  etc., 
insanities;   (3)  ambitious  insanity. 

The  degeneracies  subdivide  also  into  two  groups : 
(1)  degeneracii^s  of  evolution  or  vices  of  psj^chic 
organization ;  (2)  degeneracies  of  invohition  or  psy- 
chic disorganizations.  The  vices  of  organization 
include  four  genera:  (1)  disharmonies  (species:  de- 
fect of  balance,  originality,  eccentricity) ;  (2)  neu- 
rasthenias (species :  fixed  ideas,  impulsions,  aboulias) ; 

(3)  phrenasthenias  (species :  delusional,  reasoning, 
instinctive,  phrenasthenias) ;  (4)  monstrosities  (spe- 
cies: imbecility,  idiocy,  cretinism).  The  psychic 
disorganizations  include  but  one  genus :  the  demen- 
tias, which  are  also  summed  up  in  one  species,  simple 
dementia. 

II.  There  are  no  primary  states  of  mental  alien- 
ation other  than  the  preceding.  All  other  insanities 
do  not  exist  as  distinct  entities.  They  are  nothing 
but  associations  of   a  generalized  simple    insanity, 


144  CLASSIFICATION. 

mania   or  melancholia,  with  some   physiological  or 
pathological  process  in  the  organism. 

Snch,  in  brief,  is  the  classification  that  is  to  serve 
us  as  a  guide.  It  is,  in  effect,  in  the  order  indi- 
cated in  the  table  which  exhibits  it,  that  we  now 
pass  to  study,  under  the  head  of  special  pathology, 
the  various  primary  forms  of  mental  alienation. 


SPECIAL  PATHOLOGY. 


FIEST    SECTION 

PRIMARY  STATES  OF  MENTAL  ALIENATION. 


FIRST    CLASS 

FUNCTIONAL  ALIENATIONS 

(Insanities,    Vesanias,    Psychoses). 


FIEST    GROUP 

GENERALIZED   OR   SYMPTOMATIC   INSANITIES. 

The  generalized  insanities,  also  called  erroneously 
general  insanities,  are,  as  has  been  stated,  those  in 
which  there  is  a  permanent  reaction  of  the  mental 
disorder  on  the  whole  organism,  that  is  to  sa}^,  a  lesion 
of  the  general  activity.  Apart  from  this  fundamental 
character,  they  possess  other  fundamental  characters 
which  are  summed  up  in  this:  (1)  heredity  is  less 
frequent  and  serious;  (2)  occasional  causes  play  in 
them  a  more  important  part;  (3)  they  often  appear 
as  acute  disorders ;  (4)  they  are  essentially  curable ; 
(5)  they  frequently  are  associated  with  various  other 
physiological  or  morbid  conditions  to  form  the  com- 
pound or  symptomatic  insanities. 

The  generalized  insanities  include  two  genera: 
(1)  mania;    (2)  melancholia  or  lypemania. 

Ment.  Med.— 10. 


Cbapter  W. 

MANIA. 

I— Acute  Mania  (Typical  Mania).  II— Sub- acute  Mania 
(Maniacal  Excitation).  Ill  —  Hypee- acute  Mania 
(Acute  Delirium).  IV — Chronic  Mania.  V — Remit- 
tent AND  Intermittent  Mania. 

§1.     ACXTTE  MANIA  (TYPICAL  MANIA). 

Definition. — Acute  mania  is  the  typical  or  simple 
form  of  mania.  It  is  defined  by  Esquirol  as  "A 
cerebral  affection,  chronic,  ordinarily  afebrile,  char- 
acterized by  disturbance  and  exaltation  of  the  sen- 
sibility, the  intelligence,  and  the  will."  M.  Ball 
defines  it,  in  his  turn,  as:  "An  insanity  character- 
ized by  a  generalized  delirium,  with  marked  hyper- 
excitation  of  the  intelligence  and  a  tumultuous  desire 
for  movement." 

Etiology. — Mania  has  not,  properly  speaking,  any 
special  etiology,  and  may  recognize,  singly  or  to- 
gether, the  majority  of  the  causes  enumerated  in 
the  etiology  of  insanity  generally.  It  should  be 
remarked,  however,  that  it  attacks,  by  preference, 
subjects  of  expansive  and  excitable  temperament, 
young  persons,  the  female  sex,  and  that  it  is  most 
liable  to  occur  in  the  spring  and  during  the  summer. 


"  ACUTE  MANIA   (tYPICAL  MANIA).  147 

Symptomatology. — There  may  be  recognized  in 
acute  mania  a  period  of  invasion,  a  period  of  culniin- 
nation,  and  a  period   of  termination  or  subsidence. 

1 — Period  of  Invasion. — The  onset  of  acute 
mania  is  generally  characterized  by  a  phase  of  de- 
pression, fatigue,  vague  discomforts,  moroseness, 
together  with  certain  nervous  and  organic  disturb- 
ances, such  as  cephalalgia,  insomnia,  loss  of  appetite, 
constipation,  etc.  This  premonitory  stage  continues 
for  a  variable  period,  from  a  few  hours  to  several 
days;  when  the  general  mcdaise  passes  away,  and  at 
the  same  time  the  psychic  disorder  begins  to  appear, 
so  that  at  the  moment  the  insanit}^  really  commences, 
the  patients  often  experience  a  really  surprising  sen- 
sation of  well-being.  Little  by  little  the  excitement 
makes  its  appearance,  an  imperious  desire  for  action 
is  felt,  all  the  faculties  and  functions  become  grad- 
ually exalted.  From  this  arises  an  extreme  mobility 
in  thought  and  actions,  continual  changes  of  place, 
multiplied  projects  and  conceptions,  irritability  of 
character,  causeless  outbreaks  of  passion,  and,  fre- 
quently, a  more  or  less  pronounced  tendency  to  alco- 
holic and  venereal  excesses,  which  one  must  be  on  his 
guard  against  mistaking  for  the  causes  of  the  disease, 
of  which  they  are  really  only  among  the  earlier 
symptoms. 

In  certain  cases,  following,  for  example,  a  sudden 
suppression  of  the  menses,  or  in  periodical  insanity, 
there  is  a  very  short  stage  of  invasion,  and  the  attack 
appears,  as  it  were,  in  its  full  intensity  from  the  first ; 


148  MANIA. 

generally,  however,  there  is  a  gradual  onset;  finallj" 
in  some  instances  there  occurs  a  very  characteristic 
series  of  oscillations  between  the  excitement  and  the 
normal  condition  before  the  psychosis  takes  on  its 
continuous  character. 

In  one  of  these  wa^^s,  sooner  or  later,  the  case 
progresses  to  its  culmination. 

2 — Period  of  Cuhainatlon, — An  attack  of  acute 
mania  does  not  conform  to  any  one  invariable  de- 
scription, the  symptoms,  although  essentiall}''  the 
same,  vary  more  or  less  according  to  the  case.  It 
seems  to  me  best,  therefore,  to  study  the  principal 
characters  successively  in*  the  intellectual,  moral  or 
emotional,  and  physical  spheres  respectively. 

a.  Intellectual  Sphere. — The  characteristic  trait 
of  the  state  of  the  intelligence  in  acute  mania,  is  the 
disorderly  excitation  of  the  faculties,  which,  freed 
from  the  domination  of  the  will,  act  at  hazard  and 
without  restraint.  There  follows:  (1)  a  defect  of 
consecutivness  of  the  ideas,  which  arising  en  masse 
and  unceasingly,  accumulate,  crowd,  confuse  and 
override  each  other  without  any  apparent  connection  ; 
(2)  very  marked  incoherence  of  speech,  revealing 
the  disorder  and  the  confusion  of  the  ideas,  and 
showing  itself  by  a  constant  flow  of  words  and  un- 
connected phrases,  and  especially  by  obscene  ex- 
pressions which  are  frequent  even  from  the  mouths 
of  young  girls  of  irreproachable  antecedents.  On 
account  of  this  excessive  mobility  of  ideas,  there  are 


ACUTE  MANIA  (tYPICAL  MANIA).  149 

not,  properly  speaking,  an}^  delusions  in  mania,  and 
if  ambitious  or  persecutory  notions  manifest  them- 
selves, they  rarely  do  so  in  any  systematic  or  consec- 
utive fashion ;  (3)  another  very  important  symptom 
consists  in  the  existence  of  very  numerous  and 
varied  illusions.  Hallucinations  are,  on  the  con- 
trary, very  rare,  if  indeed  they  really  occur.  The 
illusions  in  mania  are  either  sensorial  or  mental. 
The  sensorial  illusions,  connected  with  the  hyper- 
aisthesia  of  the  organs  of  sense  and  the  precipitateness 
with  which  the  patients  respond  to  their  sensations 
without  analyzing  them,  involve  especially  the  sense 
of  sight  and  consist  in  misjudgments  of  form,  volume, 
positions,  of  objects,  persons,  etc.  The  very  charac- 
teristic mental  illusions  are  equally  common.  Also 
the  result  of  the  automatic  activity  of  the  mind,  they 
are  due  to  the  rapidity  of  impressions  and  especial^ 
to  the  hyperactivity  of  the  association  of  ideas ;  which 
gives  rise  in  these  patients  to  extraordinary  conjunc- 
tions of  ideas.  A  word  uttered  before  them  calls  up  a 
complete  scene  with  which  the  word  is  connected ;  the 
termination  of  another  word  causes  them  at  once  to 
pronounce  another  word  with  a  similar  ending;  and 
they  thus  construct  whole  sentences  by  assonances  or 
rhymes.  Similarly  the  names  or  faces  of  strangers 
about  them  recall  to  them  individuals  they  have  pre- 
viously known  and  awaken  in  them  a  whole  world  of 
memories  of  the  past  which  they  adapt  to  their  present 
life.  This  is  the  explanation  of  their  designation  of 
these  individuals  by  special  names  and  treating  them 


150  MANIA. 

as  if  old  aquaintances.  The  least  object,  the  shape  of 
a  room  or  window,  the  reading  of  a  word  or  even  of  a 
single  letter,  becomes  with  them  the  point  of  depart- 
ure for  the  most  fantastic  dreams ;  and  they  believe 
themselves  successively,  and  in  the  space  of  a  few 
minutes :  popes,  kings,  physicians,  farmers,  orators, 
women ;  in  a  palace,  a  prison,  a  hospital,  a  theatre,  etc. , 
etc.  They  assist  in  their  imaginations  in  the  strangest 
scenes.  Their  delirium  is  a  dream  in  action.  Maniacs 
that  have  recovered,  and  who,  curiously  enough,  can 
recall  day  by  day  and  minute  by  minute  what  they 
have  said  and  done  in  the  course  of  their  attack,  ex- 
plain very  well  how  the  least  word  or  object  became 
with  them  the  starting  point  of  the  most  extra- 
ordinary ideas.  We  may  say  that  the  maniac,  in 
his  acute  stage,  lives  in  a  condition  of  perpetual 
illusion. 

Their  writings  are  altogether  similar  to  their 
speech,  that  is  to  say,  incoherent,  unconsecutive, 
full  of ,  designs  and  arabesques,  of  citations  and  un- 
usual words,  and  written  in  every  direction. 

b.  Moral  or  Emotional  Sphere. — In  the  moral 
sphere  the  tableau  is  the  same  and  is  likewise 
summed  up  in  a  disordered  activity  of  the  feelings, 
instincts,  and  acts.  Hence  a  mobility,  an  incoher- 
ence, an  incessant  changing  of  the  feelings, 
affections,  and  emotions.  The  patients  weep  and 
laugh ;  they  are  pleasant  and  amiable ;  a  moment 
later  they  burst  into  yjassion  and  sometimes  into 
fury  (maniacal  furor).     At  bottom  the  maniacs  are 


ACUTE  MANIA  (TYPICAL  MANIA).  151 

not  altogether  bad,  for  they  are  incapable  of  plan- 
ning evil  on  account  of  the  variability  and  lack  of 
continuousness  of  their  impressions.  They  have, 
properly  speaking,  no  character.  As  to  the  in- 
stincts, they  are  also  morbidly  exalted,  especially  the 
sexual  instinct,  and  it  happens  too  frequently  that 
we  see  these  patients  give  themselves  furiously  to 
the  habit  of  masturbation,  or  when  they  are  at  large, 
indulge  to  complete  exhaustion  in  sexual  excess. 

With  this  disordered  excitement  of  the  mental 
and  moral  faculties  there  is  a  corresponding  excite- 
ment in  action,  which  betrays  itself  by  a  constant 
desire  to  move,  run,  leap,  dance,  to  indulge  in 
bizarre  gesticulations,  to  vociferate  and  cry  inces- 
santly. From  this  tumult  of  ideas  and  feelings, 
the  maniacs,  obedient  blindly  to  their  sensations, 
are  subject  to  continual  and  instantaneous  impul- 
sions. They  are  in  this  way  unconsciously  danger- 
ous, without  intention,  but  they  are  more  inclined 
to  break,  tear,  or  overturn  whatever  comes  in  their 
way,  from  a  sort  of  automatic  impulsion,  than  they 
are  to  conceive  and  execute  the  acts  of  homicide  or 
suicide,  which  necessitate  a  reflection  of  which  they 
are  incapable. 

c.  Physical  Sphere  {3Iorhid  Reaetioii). — Here 
also  we  encounter  a  disordered  excitation  that  re- 
veals itself  in  the  most  of  the  bodily  manifestations. 

The  general  attitude  of  maniacs  is  characteristic. 
They  are  in  perpetual  motion  and  excitement  and  no 
part   of  their  body  is  quiet.     They  display  an  in- 


152  MANIA. 

cessant  and  absolute  license  of  acts,  gestures,  sing- 
ing, laughing,  crying,  contortions;  tlie  voice  has  a 
peculiar  raucous  quality ;  the  countenance  is  animated, 
flushed;  the  eyes  sparkling;  the  dress  disordered 
and  torn;  the  females  especially  are  disheveled, 
semi-nude,  they  assume  indecent  attitudes  and  in 
some  cases  resemble  actual  furies. 

Sleep  is  nearly  or  quite  absent,  and  the  nights  are 
often  more  disturbed  than  the  day.  The  insomnia 
is  rebellious  to  all  calmatives  and  sometimes  lasts 
several  months.  General  sensibility  is  usually  much 
deadened,  and  the  patients,  in  spite  of  the  disorder 
of  their  attire,  seem  insensible  to  the  most  decided 
changes  of  temperature.  The  organs  of  special 
sense,  on  the  other  hand,  are  almost  always  the  seat 
of  a  more  or  less  marked  hyperaesthesia.  Muscular 
force  seems  to  be  increased,  in  any  event  we  see  the 
patients,  even  frail  young  females,  display  a  vigor 
of  which  we  could  hardly  believe  them  capable; 
moreover,  in  sj^ite  of  the  persistent  excitement  and 
frightful  expenditure  of  force,  the  patients  never 
§eem  exhausted. 

As  regards  the  organic  functions,  they  almost  in- 
variably are  affected  by  this  excitement.  The  pulse 
becomes  more  frequent ;  the  temperature  often  is 
elevated ;  the  respiratory  rhythm  is  quickened ;  tlie 
secretions  augmented,  especially  the  saliva,  which  is 
gotten  rid  of  by  a  sometimes  incessant  expectoration, 
and  the  perspiration  which  is  said  to  sometimes 
give  off  the  odoi'  of  mice.     The  appetite  is  exagger- 


ACUTE  MANIA   (tYPICAL  MANIA).  153 

ated,  and  some  cases  develop  a  revolting  degree 
of  voracity  and  gluttony;  constipation  msij  be 
obstinate.  The  bodily  weight  is  much  reduced,  the 
patient  becomes  more  and  more  emaciated,  and  it 
is  only  at  convalescence,  or,  on  the  other  hand,  at 
the  passage  to  the  chronic  state,  that  the  embo7ipoi?it 
begins  to  reappear.  In  females  the  menses  are 
usually  suppressed ;  when  they  persist  their  return  is 
nearly  always  the  occasion  of  an  exacerbation  of  the 
excitement. 

3 — Period  of  Termination. — An  attack  of  acute 
mania  may  end:  (1)  in  recovery;  (2)  in  death;  (3) 
by  the  passage  into  the  chronic  state. 

Recovery. — Recovery  takes  place  in  acute  mania 
in  several  different  ways. 

The  excitement  may  disappear  all  at  once,  between 
two  days,  and  tlie  patient  v/ho  fell  asleep  in  a  state 
of  acute  mania,  may  awake  in  the  morning,  per- 
fectly calm,  and  in  the  full  possession  of  his  reason ; 
often  indeed,  he  is  never  more  lucid  than  at  the  first 
moment.  This  mode  of  recovery  should  not  be 
considered  as  of  good  omen,  and  it  appears  to  be 
more  special  to  mania  of  the  intermittent  or  remit- 
tent types.  It  is  best,  therefore,  to  mistrust  it, 
and  when  it  occurs  to  be  on  one's  guard  against 
relapses. 

A  second  mode  of  recovery  is  that  by  progressive 
oscillations.  When  the  attack  is  about  to  end  there 
is  a  glimmer  of  calm,  which  repeats  itself  at  shorter 


154  MANIA. 

and  shorter  intervals,  increasing  each  time  in  degree 
and  duration,  and  alternating  with  the  return  of  ex- 
citement which  becomes  each  time  less  intense  and 
prolonged  till  it  finally  entirely  disappears. 

A  final  mode  of  recovery  is  that  by  progressive 
and  uninterrupted  decrease  of  the  symptoms.  It 
begins  with  diminution  of  the  excitement,  return  of 
sleep,  and  body  weight,  and  gradually  progresses 
till  health  is  fully  re-established.  It  is  evident  that 
this  improvement  in  the  symptoms  is  without  value 
unless  it  involves  both  the  mental  and  the  bodily 
condition,  since,  as  has  been  stated,  the  return  of 
embonpoint  coincident  with  persistence  of  the  men- 
tal disorder  is,  on  the  contrary,  a  sign  of  bad  augury. 
Aside  from  this  eventuality,  recovery  by  progressive 
amelioration  is,  like  the  preceding  mode,  a  gener- 
ally favorable  one. 

Death. — Acute  mania  rarely  terminates  in  death. 
When  this  occurs,  it  is  almost  invariably  due  to  a 
super-added  acute  delirium  or  some  organic  affection, 
especially  a  pulmonary  disease. 

Passage  to  the  Chronic  Condition. — Next  to 
recovery,  termination  by  passage  into  the  chronic 
state  is  the  most  frequent  one  in  acute  mania. 

The  critical  moment  when  the  acute  disorder 
ceases  to  be  curable,  to  become  definitely  chronic, 
is  one  of  the  most  difficult  matters  to  determine  in 
mental  medicine.  When  it  occurs,  we  see  the  ex- 
citement after  being  slightly  diminished,  persist  in- 


ACUTE  MANIA   (tYPICAL  MANIA).  155 

definitely  in  this  new  degree,  always  accompanied 
by  incoherence  and  confusion  of  ideas  while,  on  the 
other  hand,  the  strength  returns  and  bodily  nutrition 
is  re-established.  Nothing  is  more  variable  than 
the  epoch  of  this  change  to  the  chronic  state.  In 
some  cases  it  takes  place  almost  at  once,  at  the  end 
of  the  second  or  third  month  from  the  beginning  of 
the  attack;  in  others  it  has  not  yet  occurred  after 
three  or  four  years. 

PnoGREss. — Duration. — Simple  acute  mania  has 
generally  a  regular  evolution,  comprising  periods 
of  increase,  culmination,  and  decline;  but  it  may 
present  an  irregular  course,  with  times  of  arrest, 
lucid  intervals,  and  remissions.  Its  duration  is  also 
variable,  and  while  we  may  assign  it  an  average  of 
between  two  and  eight  months,  it  may  prolong  it- 
self much  more,  and  last  several  years. 

Pathological  Anatoiney. — Autopsies  in  acute 
mania  are  generally  negative ;  the  lesions  encountered 
may  be  usually  stated  as  being  comprised  in  a  gen- 
alized  hyper jemia  of  the  nervous  centres. 

Prognosis. — The  prognosis  of  acute  mania  is 
most  frequently  favorable,  as,  according  to  most 
authorities,  it  ends  in  recovery  about  twice  out  of 
three  times  when  it  is  uncomplicated. 

The  chances  of  a  cure  are  particularly  good  in  the 
first  six  months;  they  are  only  half  as  good,  the 
second  semester;  and  become  almost  nil  after  the 
third  year.     The  instances  of  recovery  after  many 


156  MANIA. 

years  that  have  been  reported  are  exceptional  and  do 
not  invalidate  the  rule. 

The  season  has  its  influence  on  the  mode  of 
tenuination.  In  general  there  are  few  cures  of 
mania  in  winter;  they  increase  in  number  in  the 
springtime,  and  it  is  in  summer  and  autumn  that  the 
greatest  number  of  recoveries  are  observed.  Also, 
the  younger  the  j^atient  the  better  the  chances  of 
recovery.  A  first  attack  is  more  curable  than  a 
second  or  a  third.  The  curability  varies  also  accord- 
ing to  the  causes  and  the  course  of  the  disorder. 

Diagnosis. — Acute  mania  is,  as  a  rule,  very  easy 
of  recognition.  Nevertheless  it  may  be  confounded, 
during  the  first  few  days,  with  a  febrile  delirium, 
marking  the  beginning  of  an  acute  affection.  The 
thermic  evolution,  however,  is.  quite  different  in  the 
two  cases. 

The  most  important  point  in  the  diagnosis  is  to 
determine  whether  the  attack  of  acute  mania  is  un- 
complicated, or  whether  it  is  symptomatic  of  any 
other  morbid  condition,  general  paralysis,  alcoholism, 
epile^jsy,  the  puerperal  state,  etc.,  etc.  This  point, 
sometimes  very  difficult  to  decide,  can  only  be  resolved 
by  a  thorough  acquaintance  with  the  symptoms  of 
the  principal  disease  and  the  peculiarities  it  impresses 
upon  the  mania  itself.  We  will,  therefore,  find  the 
elements  of  this  diagnosis  in  the  continuation  of  our 
studies. 

It  is  finally  necessary  to  ask,  in  the  presence  of 
an  attack  of  acute  mania,  whether  it  is  not  the  first  link 


SUB- ACUTE  MANIA   (mANIACAL  EXCITATION).     157 

of  a  pathological  chain,  that  is  to  say,  the  commence- 
ment of  an  intermittent  or  double  form  insanity. 
The  succession  of  attacks  can  alone  dispel  all  doubts. 
It  is  well  to  suspect  this,  as  a  rule,  when  there  is 
pronounced  hereditary  taint,  when  cases  of  intermit- 
tent or  circular  insanity  have  existed  in  the  ances- 
tors, or,  finally,  whenever  the  attack  begins  and 
ends  suddenly,  and  when  the  mind  is  never  brighter 
than  during  the  first  days  of  recovery. 

Treatment. — Isolation  as  soon  as  possible.  Dur- 
ing the  attack,  sedative  measures  of  all  kinds, 
especially  warm  baths  prolonged  for  several  hours. 
For  the  agitation  and  insomnia,  bromides, 
chloral,  paraldehyde,  methylal,  sulfonal,  hyoscy- 
amine,  hyoscine,  etc.  Derivatives  by  the  intestinal 
canal.  When  the  passage  to  the  chronic  condition 
is  threatened,  strong  revulsive  measures  may  be  tried 
and  artificial  suppuration  established.  Symptom- 
atic treatment.  In  certain  cases,  the  use  of  the  cami- 
sole and  of  artificial  feeding  may  be  required. 

§11.     SUB-ACUTE  MANIA  (MANIACAL 
EXCITATION). 

kSub-acute  mania,  or  maniacal  excitation  is  only 
the  first  degree  of  mania.  It  forms  a  variety  by  it- 
self in  the  nosological  scale,  with  its  own  special 
symptoms. 

Etiology. — Maniacal  excitation  recognizes  the 
same  causes  as  acute  mania  and  insanity  m  general ; 


158  MANIA. 

it  arises  more  often  from  heredity  than  does  simple 
mania,  and  it  may  be  said  that  the  majority  of 
maniacally  excited  individuals  are  cases  of  hereditary 
predisposition. 

DESCRiPTioisr. — Maniacal  excitation  reveals  itself 
in  an  infinite  number  of  degrees,  from  simple  hyper- 
activity of  the  physiological  operation  of  the 
intellect,  to  quite    disorderly  delirious   excitement. 

In  its  slightest  degree  it  amounts  to  merely  an 
exaggeration  of  the  psychic  activity,  and  may  thus 
form  a  part  of  the  constitutional  make-up  of  some 
individuals  who  are  all  their  lives  mild  cases  of  ma- 
niacal excitation. 

In  a  more  advanced  degree,  it  is  clearly  patholog- 
ical and  is  accomjjanied  by  well  marked  symptoms. 

In  the  intellectual  sphere  all  the  faculties  are  in  a 
state  of  extreme  exaltation.  The  over-stimulated 
imagination  leads  the  patients  to  devise  a  thousand 
projects,  no  sooner  conceived  than  abandoned ;  busi- 
ness plans,  political  and  social  schemes,  inventions, 
scientific,  artistic,  and  literary  ideas  arise  in  multi- 
tudes, but  differ  very  decidedly  from  the  delirious 
ideas  of  acute  mania,  since,  although  for  the  most 
part  unrealizable,  they  are  not  in  themselves  absurd 
and  move  constantly  within  the  range  of  possibility. 
Often,  indeed,  on  account  of  the  exaltation  of  the  fac- 
ulties, they  have  a  stamp  of  originality,  of  novelty,  or 
of  distinction  and  superiority  that  makes  them  really 
noteworthy.  Patients  in  this  condition  have  pro- 
duced useful  inventions,  solved  important  problems, 


SUB-ACTJTE  MANIA   (mANIACAL  EXCITATION).     159 

brought  out  valuable  works,  in  a  word,  have  shown 
themselves  more  intelligent  and  productive  than 
they  had  ever  been  before. 

The  memory  is  also  in  a  condition  of  functional 
hyper-excitation,  (hypermnesia) ;  sometimes  to  such 
an  extent  that  all  recollections,  even  those  that 
seemed  most  forgotten,  reproduce  themselves  en 
masse,  so  that  the  patients  recite  long  passages  from 
the  classics,  make  citations  in  all  languages  most  cor- 
rectly and  appropriately,  give  names,  dates,  and 
figures  with  surprising  accuracy;  in  short,  display 
in  detail  without  any  omissions,  all  their  acquire- 
ments, small  and  great,  that  they  have  made  since 
their  infancy. 

The  faculty  of  language  is  in  keeping  with  the 
other  faculties,  that  is  to  say,  the  animation  of  the 
excited  maniacs  is  inexhaustible.  Loquacious  to  the 
extreme,  they  express  themselves  with  extraordinary 
facility,  often  even  with  choiceness  and  elegance; 
their  discourse  is  full  of  bright  remarks,  jests,  caustic 
pleasantries  and  anecdotes  full  of  interest.  The 
same  is  true  of  their  writings  and  all  other  intel- 
lectual products  which  all  bear  the  marks  of  this 
brilliant  exaltation  of  their  faculties. 

The  character  of  the  ideas  themselves  is  extremely 
variable  and  mobile.  The  predominating  concep- 
tions are  those  of  pride,  ambition,  fortune,  vague 
persecution,  etc. ;  but  they  keep  as  a  rule  within 
the  limits  of  coherency,  and  there  are,  properly 
speaking,  no  delusions. 


160  MANIA. 

In  some  cases,  nevertheless,  the  excitation  of  the 
faculties  is  more  marked,  and  there  is  a  true  delirium, 
always  semi-coherent,  that  commonly  assumes  the 
ambitious  type  and  reveals  itself  by  ideas  of  inven- 
tion, statesmanship,  erotism,  etc.,  etc.  From  these 
there  have,  in  former  times,  been  made  a  number  of 
varities  of  intellectual  mania,  called,  according  to 
the  type  of  ruling  ideas,  ambitious  mania,  mania  of 
inventors,  erotic  mania,  etc.  When  the  maniacal  ex- 
citation is  thus  accompanied  by  delusions,  there  are 
often  added,  as  in  acute  mania,  sensorial  and  mental 
illusions,  but  not  of  as  unreasonable  a  nature.  Hallu- 
cinations never  occur,  or  at  least  if  they  are  present, 
they  are  due  to  some  superadded  morbid  condition. 

In  the  moral  or  emotional  sphere  the  hyper-excita- 
tion is  shown  generally  by  a  more  or  less  marked  ex- 
aggeration of  the  evil  tendencies  and  the  vicious  in- 
stincts. The  maniacally  excited  individuals  are,  for 
the  most  part,  vicious,  proud,  litigious,  prodigal,  ob- 
scene, malignant,  passionate,  even  violent.  They 
enjoy  ridiculing  everything,  in  plotting  mischief,  and 
are  aided  wonderfully  in  their  perverse  tendencies  by 
their  lucidity  and  shrewdness.  At  the  same  time 
they  have  frequentlj''  a  very  marked  propensity  to 
manceuvring,  to  scandal,  to  drink,  to  lewdness,  es- 
pecially when  the  attack  takes  on  an  acute  form. 
It  is  almost  only  in  general  paralysis  that  maniacal 
excitation  ever  reveals  itself  by  a  moral  erethism 
in  the  contrary  sense,  that  is  by  a  generous  disposi- 
tion and  excessive  philanthropy. 


SUB-ACUTE  MANIA   (mANIACAL  EXCITATION).     161 

Maniacal  excitement  is  nearly  always  accompan- 
ied by  bodily  activity,  but  moderated,  coherent,  and 
always  very  different  from  the  incoercible  agitation 
of  acute  mania.  There  are  also  occasional  symptoms 
of  transient  congestion,  such  as  pupillary  inequality, 
tremor,  slight  hesitancy  in  speech,  which  complicate 
the  diagnosis,  all  the  more  inasmuch  as  maniacal  ex- 
citation is  often  symptomatic  of  incipient  general 
paralysis. 

Course.  —  Duration.  —  Termination. — The  at- 
tack of  maniacal  excitation  follows  nearly  the  same 
course  and  has  about  the  same  duration  as  that  of 
acute  mania.  Its  most  frequent  termination  is  re- 
covery ;  it  rarely  passes  into  the  chronic  condition ; 
occasionally  it  is  replaced  by  an  attack  of  acute 
mania. 

Prognosis. — If  we  consider  only  the  attack  it- 
self, the  prognosis  is  very  good.  It  must  be  borne 
in  mind,  nevertheless,  that  maniacal  excitation  is 
often  only  the  first  stage  of  a  double  form  insanity 
or  an  intermittent  mania,  when  it  is  not  symptomatic 
of  commencing  general  paralysis  or  of  hysteria, 
which  sensibly  modifies  the  prognosis. 

Pathological  Anatomy. — There  is  nothing  to 
state  in  this  regard  unless  it  be  that  there  is  a  more 
circumscribed  hypersemia  than  in  acute  mania. 
Autopsies,  also,  are  very  unusual  in  this  disorder. 

Diagnosis. — Maniacal  excitation,  with  its  pathog- 
nomonic symptoms  of  intellectual  hyper-activity  is 

Ment,  Med.— 11. 


162  ma:nia. 

recognizable  at  once.  It  is  hardly  possible  to  con- 
found it  with  acute  mania,  from  which  it  is  dis- 
tinguished by  the  absence  of  disordered  agitation, 
nor  with  ambitious  delusion  (partial  insanity) which, 
aside  from  its  other  characters,  is  almost  never  pri- 
mary. It  is  much  harder  to  distinguish  the  morbid 
species  with  which  it  may  be  connected,  especially 
when  it  is  a  double  form  insanity  or  beginning  gen- 
eral paralysis.  It  should  be  remembered  that  in 
these  cases  of  double  form  insanity  the  physical 
symptoms  are  often  lacking,  the  conceptions  are 
never  absurd  or  demented,  and  finally  that  the 
patients  are  thoroughly  vicious  and  dangerous. 

Treatment. — When  maniacal  excitation  attains 
a  certain  height  it  is  almost  always  necessary  to  se- 
questrate the  patients,  on  account  of  danger  to  their 
families  and  to  society.  Otherwise  the  same  treat- 
ment as  for  acute  mania  is  applicable. 

§111.     HYPER- ACUTE  MANIA  (ACUTE  DELIRIUM). 

Acute  delirium  lacks  a  definite  position  in  the 
list  of  mental  diseases.  According  to  some  authori- 
ties, it  is  a  morbid  entity,  according  to  others,  a  mere 
symptom  or  complication.  In  reality  it  maybe  con- 
sidered as  the  highest  degree  of  mania,  of  which  it 
forms,  by  its  peculiar  characters,  a  special  variety. 

Etiology. — Acute  delirium  is  usually  the  se- 
quence of  grave  moral  or  physical  disturbances.      It 


HYPEE- ACUTE  MANIA  (aCUTE  DELIRIUm).        163 

is  especially  symptomatic,  that  is  to  say,  connected 
with  different  morbid  conditions,  such  as  general 
paralysis,  alcoholism,  puerperal  states,  etc. 

Description. — The  commencement  of  the  disor- 
der is  nearly  always  marked  by  a  period  of  premon- 
itory depression,  that  in  some  cases  may  suggest  an 
incipient  melancholia.  There  has  CA'^en  been  de- 
scribed a  melancholic  form  of  acute  delirium,  but 
this  seems  more  properly  to  belong  to  the  type  of 
melancholia  with  stupor.  Generally,  after  a  longer 
or  shorter  depressive  phase,  the  agitation  makes  its 
appearance  and,  in  a  few  days,  sometimes  only  a 
few  hours,  it  reaches  its  maximum  of  intensity. 
The  tongue  becomes  dry,  the  fever  quickens,  the 
pulse  is  over  120,  the  temperature  rises  rapidly  to 
4:0°  or  41^  (=104^  to  105.8*^  F.),  the  head  is  hot, 
the  eyes  wild,  the  skin  covered  with  a  viscous  per- 
spiration. The  patients  appear  terrified;  they  are 
the  prey  of  an  intense  agitation ;  they  give  utter- 
ance to  incessant  cries,  they  expectorate  constantly 
their  saliva  in  whitish  sputa,  have  a  horror  of  food, 
and  sometimes  even  exhibit  symptoms  of  hydropho- 
bia. The  reflexes  are  exao;<yerated  and  the  least  ex- 
citation  produces  convulsive  attacks. 

At  this  moment,  a  cure  is  still  possible  by  gradual 
defervescence,  followed  usually  by  a  long  convales- 
cence; but  the  usual  termination  of  the  disease  is 
death  between  the  fifth  and  tenth  day.  When  this 
is  to  occur  the  fever  increases;  a  sort  of  coma  suc- 
ceeds the  agitation ;  the  pulse  becomes  more  rapid 


164  MANIA. 

and  weaker;  the  tougue  and  lips  are  covered  with 
dark  colored  crusts,  the  breatli  is  fetid,  the  respira- 
tion puffing ;  the  urine  and  faeces  are  passed  involun- 
tarily, insomnia  is  persistent;  subsultus  of  the  ten- 
dons and  general  or  partial  convulsions  appear; 
typhoid  symptoms  make  their  appearance ;  diarrhoea 
occurs,  the  pulse  becomes  imperceptible,  coma  is 
deeper  and  deeper;  finally  faihire  approaches  and  the 
patient  dies,  either  suddenly  in  syncope  or  slowly 
from  nervous  exhaustion. 

Pathological  Anatomy. — In  most  cases  of  sim- 
ple or  vesanic  acute  delirium  we  find  no  apparent 
lesions  at  the  autopsy  (acute  delirium  without 
lesions) ;  it  is  only  when  the  disorder  is  S3nnptom- 
atic  of  some  other  affection  (general  paralysis, 
alcoholism),  that  we  encounter  marked  alterations, 
especially  of  the  congestive  type.  They  consist  of 
venous  stasis  and  swelling  of  the  brain  with  prondn- 
ence  of  the  convolutions,  whitish  streaks  on  the 
vessels  of  the  pia,  engorgement  of  the  lymphatics, 
sanguineous  extravasations  scattered  in  the  cerebral 
parenchyma,  injection  of  the  meninges  with  adher- 
ences  to  the  cortex,  pink  tint  of  gray  matter,  (jedema 
of  the  convolutions,  increase  of  cephalo-rhachidian 
fluid,  etc.,  and,  in  the  viscera,  various  traces  of  con- 
gestion. 

Briand  counts  acute  delirium  among  the  infectious 
disorders.  He  foun<l  bacteria  in  the  urine  and  in 
the  blood.      It  is,  in  fact,  probable  that  acute  delir- 


CHRONIC    MANIA.  165 

iiim  is  tlie  result   of    an  auto-intoxication;  in  any 
case  it  deserves  investigation  in  this  direction. 

Diagnosis. — Acute  delirium  may  be  confounded 
with  typhoid  fever  or  pneumonia,  and  cases  occur 
when  only  the  autopsy  can  decide.  Nevertheless, 
the  evolution  of  the  disorder,  careful  examinations 
of  all  the  organs,  and  especially  the  temperature 
curve  will  usually  furnish  the  requisite  elements  for 
the  diagnosis. 

Treatment. — -Treatment  is  essentially  symptom- 
atic. It  consists  in  fortifying  and  nourishing  the 
system,  keeping  the  patients  in  quiet  and  darkened 
rooms,  in  order  to  restrain  their  agitation,  and  the 
use  of  the  usual  sedatives  and  hypnotics.  In  the  be- 
ginning, attempts  may  be  made  to  prevent  or  atten- 
uate auto-intoxication  by  antisepsis  of  the  intestinal 
and  the  digestive  tract. 

§IV.     CHRONIC  MANIA. 

Chronic  mania  is  rarely  a  primarjr  disorder.  It 
commonly  follows  acute  mania,  of  which  it  is,  as  we 
have  seen,  one  of  the  modes  of  termination.  It  is 
not  therefore,  properly  speaking,  a  special  variety 
of   insanity. 

It  is  characterized  essentially  by  the  indefinite 
persistence  in  an  attenuated  form  of  the  symptoms 
of  mania.  There  is  no  longer  the  violent  and  in- 
coercible  agitation,  but  there  is  a  more  moderate 
excitement,  varied,  at  differing  inteiwals,  by  exacer- 


166  MANIA. 

bation  resembling  the  preceding  acute  form.  The 
special  distinguishing  mark  of  chronic  mania, 
however,  is  that  the  delusive  ideas,  so  mobile  and 
transitory  in  acute  mania,  here  gradually  assume  a 
fixedness  and  consistency,  so  that  they  resemble,  in 
some  cases,  a  true  systematized  insanity.  This  type, 
Avhich  has  hardly  been  studied  in  France,  and  which 
has  elsewhere  received  the  designation  of  secondary 
systematized  insanity  or  secondary  paranoia,  takes 
on  usually  the  ambitious  form.  It  is  not  always 
easy  to  distinguish  it  from  primary  or  essential 
systematized  insanity,  and  only  an  acquaintance  with 
the  antecedents  can  clear  up  the  diagnosis  in  some 
cases. 

Chronic  mania  is  incurable.  When  death  does 
not  occur  from  a  visceral  or  cerebral  complication,  it 
terminates  in  dementia,  which  then  bears  the  name 
of  raaniacal  dementia^  from  its  origin  and  the  per- 
sistence amid  the  mental  ruin,  of  some  symptoms 
recalling  the  condition  of  the  preceding  mania. 
Life  may  thus  be  prolonged  for  many  years. 

^V.     REMITTENT  AND   INTERMITTENT  MANIA. 

Remittent  mania  is  a  variety  of  continued  mania, 
characterized  by  the  more  or  less  regular  return  of 
acute  crises  or  ]>aroxysmH,  separated  by  periods  of 
attenuations  or  remissions. 

Strictly  speaking,  chronic  mania  might  take  its 
place  with  remittent  mania  as  it  is  likewise  formed. 


REMITTENT  AND  INTERMITTENT  MANIA.  167 

in  most  cases,  of  alternating  remissions  and  exacerba- 
tions. In  it,  however,  these  alternatives  are  neither 
constant  nor  regular,  nor  identical,  as  in  true  remit- 
tent mania  where  the  regular  alternation,  often  even 
periodical,  between  the  remission  and  the  exacerba- 
tion, forms  the  fundamental  element  of  the  disease. 

Usually  the  order  is  as  follows :  An  attack  of 
acute  mania  occurs,  passes  its  culmination  and  de- 
clines. A  decided  improvement  is  believed  to  be  des- 
tined to  end  in  recovery,  but  after  a  while  a  new 
acute  attack  appears  followed  by  another  improve- 
ment, and  so  on  for  years.  The  morbid  succession 
is  thereafter  regular. 

Intermittent  mania  differs  from  remittent  mania 
in  that  the  attacks  are  not  separated  by  simple 
periods  of  amelioration  or  remissions,  but  by  inter- 
vals of  complete  return  to  the  normal  condition  or 
intermissions.  Remittent  mania  is  therefore  a  con- 
tinuous insanity  with  exacerbations,  while  intermit- 
tent mania  is  an  insanity  of  attacks  alternating  with 
the  normal  mental  condition.  This  distinction  is 
especially  important  in  a  medico-legal  point  of 
view. 

True  intermittent  mania  is  that  in  which  the 
attacks  and  intermissions  succeed  each  other  always 
in  a  regular  and  identical  manner.  The  return  of 
the  different  phases  often  then  coincides  with  the 
return  of  certain  seasons.  It  is  rarely,  however, 
that  the  insanity  realizes  so  perfect  an  isochronism, 
and  its  periodicity  is  therefore  more  often  only  rela- 


168  MANIA. 

tive.  The  attack  is  sometimes  longer  or  shorter, 
lighter  or  more  severe;  sometimes  it  is  the  intermis- 
sion that  is  longest ;  it  lasts  sometimes  several  years. 

Intermittent  and  remittent  mania  in  nowise  form 
varieties  in  a  symptomatic  point  of  view,  and  the 
attacks  composing  them,  taken  in  themselves,  are 
only  the  ordinary  ones  of  acute  mania  and  maniacal 
excitation. 

What  distinguishes  them  and  gives  them  a  par- 
ticular physiognomy  is:  (1)  that  the  attacks  are 
reproduced   in    a    more    or    less    regular    fashion; 

(2)  that  they  are  usually  identical  with  each  other ; 

(3)  that  they  begin  and  end,  as  a  rule,  suddenly ; 

(4)  that  they  are  always  separated  by  remissions  or 
intermissions ;  (5)  that  the  duration  of  their  alterna- 
tion is  indefinite  and  ceases  only  when  chronicity 
or  dementia  ensues. 

It  is  necessary  to  add,  for  the  sake  of  complete- 
ness, that  remittent  and  intermittent  mania,  like  in- 
sanity of  double  form,  are  rather  special  to  the 
hereditarily  disposed  and  degenerates.  For  this 
reason,  several  French  and  foreign  authors  (Morselli, 
Magnan)  rank  these  forms,  under  the  generic  name 
of  cyclical  insanity,  in  the  mental  state  of  the  degen- 
erates. 

The  return  of  the  attacks  may  also  be  influenced 
by  different  occasional  circums,tance8,  the  seasons, 
the  return  of  the  menses,  etc.,  and,  according  to  Dou- 
trebente,  the  intermittent  insanities  are  at  bottom 
related  to  the  great  neurosis  epilepsy.     According 


REMITTENT   AND  INTERMITTENT  MANIA.  169 

to  other  memoirs,  quite  recently  published,  the  in- 
termittent maniacs  more  especially  belong  to  the 
class  of  diathetic  cases  whose  attacks  of  insanity  cor- 
respond each  time  to  acute  attacks  of  auto-intoxica- 
tion (Mabille  and  Lallemand,  1890). 

Treatment. — Anti-periodics,  quinine  in  particu- 
lar, in  large  doses  have  been  recommended  to  combat 
the  intermittence,  but  the  results  have  hardly  been 
favorable.  The  attacks  need,  in  reality,  the  same 
treatment  as  the  ordinary  ones  of  acute  mania. 
A  certain  number  of  patients  have  recourse  to  the 
asylum  of  their  own  accord  as  soon  as  they  feel  the 
coming  on  of  the  attack. 


(Tbapter  ID. 

MELANCHOLIA   OR   LYPEMANIA. 

1. — Acute  Melancholia  (Typical  Melancholia).  II. — 
Sub-acute  Melancholia  (Melancholic  Depression). 
III. — Hyper-acute  IMelancholia  (Melancholia  with 
Stupor).  IV. — Chronic  Melancholia.  V. — Remittent 
and  Intermittent  Melancholia. 

§1.     ACUTE    MELANCHOLIA   (TYPICAL 
MELANCHOLIA). 

Definition. — Melancholia,  says  Marc6,  is  a 
mental  disorder  characterized  by  delirium  of  a 
sorrowful  nature  and  a  depression  carried  sometimes 
to  the  extent  of  stupor. 

It  will  be  more  exact  to  say  that  melancholia  is  a 
generalized  insanity  with  delirious  concentration  of 
the  mind  on  sad  ideas,  and  with  a  painful  reaction 
on  the  organism. 

Etiology. — In  contrast  to  mania,  which  attacks, 
by  preference,  subjects  of  expansive,  exuberant,  and, 
naturally  excitable  disposition,  melancholia  occurs 
mostly  in  timid,  reserved,  timorous  and  scrupulous 
individuals.  For  this  reason  it  is  much  more  fre- 
quent amongst  women  than  men.  The  proportion 
is  about  2,038  females  to  1,099  males,  while  in  mania 
the  ratio  is  2,988  females  to  2,679  males  (Planat), 


ACUTE    MELANCHOLIA.  171 

The  most  frequent  causes  of  melancholia,  apart  from 
heredity,  are  violent  emotions,  prolonged  grief, 
bodily  fatigue,  the  puerperal  condition,  and  visceral 
affections,  that  is  to  say,  debilitating  and  depressing 
causes.  More  frequently  than  is  commonly  believed, 
it  is  the  immediate  result  of  an  auto-intoxication, 
especially  a  gastro-intestinal  one. 

Symptomatology. — Acute  melancholia  presents 
a  period  of  invasion,  one  of  culmination,  and  one  of 
termination  or  decline. 

1 — Period  of  Invasion. — The  onset  of  melancho- 
lia is  still  slower  than  that  of  mania.  It  may  com- 
mence with  gastro-intestinal  disorders,  such  as  the 
saburral  state,  constipation,  anorexia,  etc.,  or  even 
be  consecutive  to  a  more  or  less  ancient  dyspepsia. 
There  are  at  the  same  time  general  malaise,  weak- 
ness, depression,  insomnia,  disgust  at  everything, 
anxiety.  In  the  very  beginning  we  sometimes  see  an 
obstinate  tendency  to  worry  in  regard  to  the  health, 
money  matters,  business,  family  affairs,  and  past  con- 
duct, etc.  But,  aside  from  the  fixedness  of  these 
ideas  and  the  disquiet  they  cause,  the  mind  seems 
unimpaired,  and  it  is  often  only  after  the  patient  has 
made  an  attempt  at  suicide  that  those  around  hhn 
begin  to  believe  in  his  insanity. 

This  premonitory  stage  lasts  for  a  longer  or  shorter 
period,  but  the  symptoms  become  gradually  worse 
and  the  stage  of  full  development  of  the  disorder  is 
reached. 


172        MELANCHOLIA  OR  LYPEMANIA. 

2 — Period  of  Full  Development  or  Culmination, — 
We  shall  here  describe,  as  was  doue  in  regard  to 
mania,  the  psychic  and  the  physical  disorders  of 
this  stage. 

a.  Disorders  of  the  Psychic  Functions.  — In  the  in- 
tellectual sphere,  strictly  speaking,  the  principal  symp- 
toms consist  in  a  painful  concentration  of  the  mind, 
a  characteristic  delusive  tendency,  and  hallucination. 

The  painful  mental  concentration  reveals  itself  by 
a  limitation  and  fixedness  of  the  ideas,  in  contrast  with 
their  mobility  and  diffuseness  as  we  observe  them  in 
mania.  Here  the  whole  being  is  painfully  filled  with 
one  set  of  ideas  and  is  absorbed  in  their  inces- 
sant meditation.  "  Animi  angor  in  una  cogitatione 
defixus  atque  inhaerens'''  as  Aretaeus  has  well  ex- 
pressed it.  With  this,  there  is  more  or  less  complete 
lucidity  in  regard  to  everything  unconnected  with 
the  delusions,  so  that  the  mind  seems  affected  only 
on  this  one  point.  Foi*  this  reason  melancholia  was 
classed  before  Baillarger,  among  the  partial  insanities 
or  monomanias  {lypemania  or  monomania  triste  of 
Esquirol) . 

The  delusions  of  acute  melancholia  are  character- 
istic. They  may  be  extremely  variable  in  expression, 
but  the  basis  is  always  the  same :  They  are  composed 
of  painful  conceptions,  such  as  ideas  of  ruin,  impo- 
tence, hypochondria,  damnation,  vague  persecutions, 
poison,  disgrace,  but  esj^ecially  of  culpability  and  im- 
aginary crimes.  The  patients  believe  themselves  lost, 
covered  with  disgrace,  they  go  back  over  the  thou- 


ACUTE    MELANCHOLIA.  173 

sand  details  of  their  lives  and  find  unpardonable  sins 
for  which  they  are  condemned  to  terrible  punishments 
or  to  death ;  they  reproach  themselves  for  all  they 
have  done  and  said ;  they  accuse  themselves  of  lack- 
ing affection  for  their  parents,  and  of  having  caused 
their  ruin  or  death;  they  have  offended  God,  made 
wrong  confessions,  committed  sacrilege,  lost  the 
world  and  merit  hell-fire ;  they  think  they  are  objects 
of  every  one's  condemnation.  Pusillanimous  and 
timid  in  the  highest  degree,  they  are  afraid  to  go  alone, 
they  fear  everything  without  knowing  why,  they  be- 
believe  themselves  in  prison,  surrounded  with  jailors, 
executioners,  etc.  Unlike  the  victims  of  persecutory 
delusions,  who  refer  their  torments  to  the  external 
world  and  accuse  others  for  everything  they  suffer,  the 
melancholiacs  refer  all  the  evil  that  occurs  around 
them  to  themselves  and  accuse  themselves  of  being  its 
cause.  The  distinction  is  characteristic,  and,  more 
than  any  other  symptom,  aids  the  diagnosis,  which 
presents,  at  times,  some  difficulties. 

Corresponding  with  these  delusions,  there  is  a  spe- 
cial symptom  in  the  speech.  The  patients  talk  but 
little,  in  a  dull  tone,  slow  and  lugubrious,  and,  except 
in  the  groanings  and  complaints  they  utter,  they  have 
to,  as  it  were,  force  out  the  words  they  use.  Some- 
times there  is  even  complete  mutism.  They  also  write 
very  little  or  none  at  all. 

Hallucinations  are  nearly  constant  in  acute  mel- 
ancholia. They  may  be  multiple  and  involve  sev- 
eral senses,   nevertheless,  those   of  hearing  are   the 


174  MELAKCHOLIA  OR  LYPEMANIA. 

most  frequent.  The  patients  hear  night  and  day, 
but  especially  at  night,  voices  accusing  and  re- 
proaching them  and  threatening  them  with  various 
punishments;  they  see  phantoms,  death's-heads, 
angels,  the  fires  of  hell,  dramatic  or  terrifying 
scenes,  such  as  battles,  massacres,  etc.,  etc.  They 
claim  to  smell  bad  odors ;  their  food  has  the  taste  of 
human  flesh;  they  feel  disagreeable  sensations,  are 
rotten,  etc.,  etc.  Sometimes  also  they  experience 
internal  illusions,  genital  or  intestinal,  of  the  most 
varied  nature. 

In  the  moral  or  emotional  sphere  the  disorder  may 
assume  either  of  two  different  forms.  Either  the 
patients  are  apathetic  and  indifferent,  not  only  to 
what  concerns  themselves,  but  also  to  whatever  af- 
fects their  family  and  whoever  is  most  dear  to  them, 
going  so  far  sometimes  as  to  have  a  positive  aversion 
to  them,  or,  on  the  other  hand,  their  affective  senti- 
ments are  in  a  condition  of  exaltation,  and  they  are 
in  a  state  of  morbid  preoccupation  about  their  rela- 
tives and  friends.  At  the  same  time,  they  are  gen- 
erally anxious,  self -tormented,  lacking  in  will,  and 
live  in  a  state  of  perpetual  apprehension. 

The  instincts  are,  for  the  most  part,  blunted  and 
without  reaction. 

As  regards  morbid  actions,  they  are  character- 
istic. In  fact,  there  are  two  tendencies  almost  inev- 
itably connected  with  acute  melancholia;  they  are: 
(1)  refusal  of  food  (2)  the  suicidal  tendency. 

Refusal  of    food,  in  some   degree,  is  almost  the 


ACUTE    MELANCHOLIA.  I'J'S 

rule.  It  arises  from  the  delusive  ideas  of  the  pa- 
tients who  think  they  are  dishonored,  ruined,  and 
unable  to  pay  for  their  food,  whence  they 
declare  that  they  feel  no  hunger,  are  unfit  to 
eat  or  wish  to  do  penance.  This  refusal  of  food  is 
also  induced  by  the  gastro-intestinal  disorders  nearly 
always  existing.  Sitiophobia  in  melancholiacs  pre- 
sents special  characters  which  it  is  necessary  to  rec- 
ognize. The  patients,  being  incapable  of  any 
energetic  exercise  of  the  will,  do  not  generally  offer 
an  obstinate  or  invincible  opposition,  like  those 
suffering  w^ith  delusions  of  persecution  for  example. 
Theirs  is  an  inert,  passive  refusal,  without  firmness, 
so  that  sometimes  it  is  possible  to  make  them  take 
food  from  a  nipple  like  infants ;  it  is  often  necessary, 
nevertheless,  to  use  continuously  the  methods  of 
artificial  alimentation. 

As  to  the  tendency  to  suicide,  it  exists  almost  invari- 
ably to  some  extent  in  acute  melancholia,  and  exhibits 
itself  with  the  same  characters  of  inertia  and  inde- 
cision as  the  refusal  of  food.  The  melancholiac  has 
a  strong  enough  desire  to  die,  as,  with  all  the  morbid 
ideas  that  haunt  his  brain,  life  is  a  burden ;  but  he 
is  most  frequently  incapable  of  making  a  serious 
effort  to  destroy  himself  or  to  employ  the  least 
energy  in  carrying  out  the  project.  It  seems  to 
him  that  death  ought  of  itself  to  come  to  him.  There- 
fore, in  many  instances,  his  attempts  are  imperfect 
and  ridiculous.  Some  patients  limit  themselves  to 
thrusting  pins  through  the  skin,  or  swallowing  some 


176  MELANCHOLIA  OE  LTPEMANIA. 

inofl'eusive  substance,  others  tie  a  cord  or  handker- 
chief around  the  neck  and  leave  it  there  without  hav- 
ing the  energy  to  draw  it  tight.  The  majority  con- 
sider a  long  time  over  their  project,  they  take  up 
again  and  again  the  weapon  or  the  poison  they  have 
chosen ;  in  short,  they  manifest  an  absolute  want  of 
initiative  or  decision.  Such  are  the  usual  characters 
of  the  suicidal  tendency  in  the  melancholiacs,  but  it 
must  not  be  forgotten  that  no  absolute  rule  can  be 
laid  down,  and  that  these  patients  may,  under  the 
influence  of  a  sudden  impulse  or  an  unforeseen  ac- 
cession of  energy,  make  Avay  with  themselves  sud- 
denly and  without  hesitation  [raptus  raelancholicus.) 

b.  Disorders  of  the  Bodily  Functions. — The  in- 
sane, like  normal  individuals,  do  not  all  react  in  the 
same  fashion  under  the  influence  of  painful  emotions. 
Some  keep  all  their  troubles  to  themselves  and  let 
nothing  escajDe  them,  so  that  their  physical  activity 
is  in  an  inverse  ratio  to  their  psychic  exaltation.  In 
others,  on  the  contrary,  the  suffering  manifests  itself 
by  disturbed  or  anxious  activity  and  this  bodily  reac- 
tion is  in  direct  proportion  to  the  delirious  exaltation. 
There  are,  therefore,  two  types  of  melancholiacs  as 
regards  attitude  and  external  manifestations :  the  de- 
pressed and  the  exalted  types. 

The  depressed  cases  have  a  corresponding  appear- 
ance, the  head  hanging,  the  arms  pendent,  movements 
slow,  gestures  infrequent,  the  physiognomy  is  altered, 
the  features  drawn,  the  face  thin  and  pale,  the  expres- 
sion sad,   the  aspect    gloomy  and  dull,   the    fore- 


ACUTE    MELANCHOLIA.  177 

head  wrinkled,  the  mouth  contracted ;  they  are  im- 
movable, inert  and  passive,  it  is  necessary  to  dress 
them,  make  them  rise,  walk,  or  eat,  without  com- 
pulsion they  will  do  nothing.  It  is  only  on  rare 
occasions  that  they  are  seized,  all  at  once,  with  a  kind 
of  impulsive  attack  during  which  they  give  them- 
selves up  to  automatic  acts  of  violence  (raptus). 

The  exalted  cases,  on  the  other  hand,  have  a  dis- 
turbed countenance,  the  eyes  bright,  the  manner  anxi- 
ous or  terrified.  Their  feelings  manifest  themselves 
in  tears,  cries,  groanings,  disconnected  complainings, 
jerky  gestures,  and  the  constant  identical  repetition 
of  certain  mechanical  acts.  They  undress  themselves, 
tear  their  apparel,  twist  their  fingers  and  lips,  and  tear 
the  skin  of  their  hands  and  face  without  feeling  it  or, 
as  it  were,  without  paying  to  it  any  attention. 

In  all,  the  sleep  is  disturbed  and  unsatisfactory, 
troubled  by  dreams,  nightmares  and  hallucinations. 

The  sensibility  is  very  obtuse,  occasionally,  so  to 
speak,  abolished.  The  special  sensory  functions  are 
likewise  weakened  and  retarded. 

The  respiration  is  slow,  incomplete,  and  its  ratio  to 
the  cardiac  rhythm  reduced.  Hsematosis  is,  there- 
fore, interfered  with,  which  fact  explains  the  frequent 
occurrence  of  passive"  congestions  of  the  lungs  in 
melancholiacs. 

The  heart  beats  with  less  energy  and  its  move- 
ments are  slower.  The  pulse  is  variable,  sometimes 
it  reaches  100  or  120,  sometimes  it  falls  to  35  and 
40  per  minute.     Bodily  temperature  is  lowered,  es- 

MsiNT.  Med.— IS, 


178  MELANCHOLIA  OR  LYPEMANIA. 

pecially  at  the  periphery  where  it  may  fall  three 
or  four  degrees  (Centigrade).  The  extremities 
(hands,  nose,  ears)  are  chilled  and  cyanosed. 

Gastro-intestinal  complications  are  almost  invari- 
ably encountered.  They  consist  in  a  saburral  con- 
dition of  the  digestive  passages,  dyspepsia  with 
hyperacidity,  flatulence  and  constipation.  These 
disorders  are  in  part  responsible  for  the  refusal  of  food 
and  are  among  the  causes  of  the  emaciation  it  pro- 
duces. The  breath  of  melancholiacs  is  strong  and 
offensive,  especially  in  patients  that  do  not  eat.  The 
secretions  are  also  diminished,  and  the  same  usually 
occurs  in  the  genital  activity. 

3.  Period  of  Termination  -or  Decline. — Acute 
melancholia  may ,  terminate,  like  mania,  (1)  in 
recovery;  (2)  by  death;  (3)  by  passing  into  the 
chronic  state.  _^ 

Recovery. — This  is  the  most  frequent  termina- 
tion. It  occurs  customarily  by  a  progressive  re- 
awakening of  activity,  return  of  sleep,  and  gradual 
disappearance  of  the  delusive  conceptions.  Very 
frequently  there  is  left  a  residue  of  general  depres- 
sion and  obtusion  of  the  faculties  that  continues 
for  a  longer  or  shorter  time  after  recoverv^ 

Death. — Termination  in  death  is  not  rare, 
especially  in  debilitated  cases.  It  occurs  either 
from  a  gradual  enfeeblement,  the  result  of  inanition, 
from   bodily  decay,  or  from  some  visceral  compli- 


ACUTE    MELANCHOLIA.  179 

cation,     diarrhcea,      pulmonary     congestion,      etc. 
Finally,  death  may  be  from  suicide. 

Passage  to  the  Chronic  State. — Passage  to  the 
chronic  condition  is  less  frequent  than  in  mania. 
When  it  occurs,  the  depression  decreases,  but  per- 
sists in  a  subacute  form,  the  delusions  and  hallu- 
cinations become  fixed  -and  permanent,  while  the 
general  bodily  health  is  in  whole  or  in  part  re- 
established. 

Forms  of  Acute  Melancholia. — Many  authors 
admit  the  existence  of  various  forms  of  acute  melan- 
cholia, and  distinguish:  religious,  demoniac,  hypo- 
chondriacal and  suicidal  melancliolias ;  also  depres- 
sive, anxious,  groaning,  panophobic  varieties,  etc. 
etc.  Fundamentally  there  is  onh^  one  disease,  acute 
melancholia,  varying  in  its  aspect  only  as  it  is  looked 
at  from  the  point  of  view  of  predominating  tenden- 
cies and  ideas  or  from  that  of  its  general  attitude 
and  mode  of  external  reaction. 

Course  and  Duration. — Acute  melancliolia  has 
habitually,  like  mania,  a  regular  course,  susceptible 
of  division  into  distinct  periods.  It  is,  notwithstand- 
ing, particularly  subject,  during  its  course,  to  fre- 
quent, more  or  less  marked,  oscillations.  Its  duration 
is  generally  longer  than  that  of  mania,  as  recovery 
rarely  takes  place  before  three  or  four  months.  It 
occurs,  on  the  average,  between  the  sixth  and  the 
twelfth  month. 


180        MELANCHOLIA  OE  LTPEMANIA. 

Pathological  Anatomy, — The  lesions  of  acute 
melancholia  are  hardly  known.  They  consist,  it  is 
said,  in  an  ischremia  of  various  regions  of  the  brain. 
The  visceral  alterations,  particularly  those  of  the  ab- 
domen, are  perhaps  more  constant  and  pronounced. 
This  is  the  reason  why  so  much  influence  has  always 
been  attributed  to  them  in  the  production  of  melan- 
cholia, whatever  might  be  the  mechanism  (sym- 
pathy, auto-intoxication.) 

Prognosis. — The  prognosis  of  acute,  uncompli- 
cated melancholia  is  almost  as  good  as  that  of  acute 
mania.  When  melancholia  is  symptomatic,  the  prog- 
nosis varies  according  to  the  affection  with  which  it 
is  allied.  In  opposition  to  mania,  melancholia  is 
aggravated  in  autumn  and  winter,  and  recovers 
easily  in  the  spring.  It  is  especially  serious  on 
account  of  the  morbid  acts  it  induces,  refusal  of  food 
and  tendency  to  suicide. 

Diagnosis. — Acute  melancholia  may  be  mistaken 
for  typhoid  fever,  especially  in  the  beginning  when 
it  is  accompanied  with  accelerated  pulse  and  a 
saburral  condition  of  the  digestive  canal.  The  char- 
acter of  the  delirium  and  the  course  of  the  temper- 
ature suffice  usually  to  clear  up  all  doubts. 

Melancholia  with  predominating  ideas  of  perse- 
cution may  be  taken  for  progressive  systematized 
insanity.  Tlie  general  depression,  the  absence  of  the 
fixedness  of  the  delusions  and  hallucinations,  the 
suicidal  tendency,  and,  finally  the  humility,  and  con- 


ACUTE    MELANCHOLIA. 


181 


trition  of  the  patient,  form  the  principal  differential 
signs. 

The  important  point  for  diagnosis  is  whether  the 
melancholia  is  simple,  or  allied  with  some  morbid 
state,  such  as  alcoholism,  general  paralysis  or  some 
visceral  disorder.  We  should  never,  therefore,  neg- 
lect to  search  in  melancholiacs  for  somatic  disorders, 
and  especially  to  examine  the  different  viscera  and 
organs  of  the  economy. 

Treatment. — At  the  commencement,  moral  treat- 
ment by  traveling  and  recreations,  aided  by  general 
therapeutic  agents  like  hydrotherapy  and  electricity, 
may  be  tried.  These,  however,  generally  fail.  The 
best  results,  in  mitigating  or  keeping  down  the  attack, 
are  obtained  by  instituting  a  medical  treatment  in- 
tended to  combat  the  phenomena  of  auto-intoxica- 
tion (repeated  purgation,  gastro-intestinal  antisepsis, 
etc.) 

When  the  disease  is  fully  established,  asylum  treat- 
ment is  nearly  always  necessary,  for  the  triple  pur- 
pose of  isolation,  treatment,  and  oversight  of  the 
patient,  whom  it  is  always  necessary  to  guard  against 
possible  attempts  at  suicide.  There  may  be  em- 
ployed, according  to  the  case,  hydrotherapy,  wet  pack, 
Russian  or  Turkish  baths,  mustard  baths,  dry  fric- 
tion, or  electricity  (galvanism  and  faradism).  Suit- 
able food,  and,  if  needed,  forced  alimentation,  should 
be  administered.  Nervous  sedatives  and  Iwpnotics 
(bromides,  chloral,  injections  of  cocaine  (Mor- 
selli  and  Buccola),  tincture  of  nux  vomica  and  laud- 


182        MELANCHOLIA  OR  LYPEMAXIA. 

anum  in  progressive  doses),  combined  with  confine- 
ment to  bed,  daily  purgatives  and  douches  (Bell  and 
Lemoine).  Tonics  (quinine,  iron,  caffeine,  kola, 
jDeptones).  Rejoeated  purgations.  Methodic  lavage 
of  the  stomach  (alkaline,  acid  or  antiseptic,  according 
to  the  case).  Complications  are  to  be  treated  as 
they  occur. 

^n.     SUB-ACUTE  MELANCHOLIA. 
(Melancholic  Depression). 

This  variety  of  melancholia  also  bears  the  name 
of  melancholia  with  consciousness. 

Etiology. — Heredit}^  very  common.  Arthritism 
(Rouillard).  Predominance  of  female  sex.  Influ- 
ence of  menstruation  and  especially  of  the  meno- 
pause. 

Description. — The  beorinnincr  of  the  attacks  is 
usually  more  sudden  than  in  acute  melancholia. 
They  may  occur  either  in  the  non-delusional  or  the 
delusional  form.  In  the  first  the  whole  is  comprised 
in  or  limited  to  a  general  condition  of  depression,  in- 
action, and  impotence.  ^The  patients  avoid  all  labor, 
all  occupation  and  all  society;  they  isolate  them- 
selves in  their  rooms,  where  they  stay  sometimes  for 
weeks  and  whole  months,  not  wishing  to  see  any 
one,  passing  their  time  seated  or  in  bed,  incapable 
of  wishing  or  deciding  or  of  making  an  effort.  This 
is  simple  melancholic  depression,  which  is  also  called. 


SUB-ACUTE    MELANCHOLIA.  183 

according  to  the  case,  moral  hypochondria,  misan- 
thropic melancholia,  perplexed  melancholia,  aboulic 
melancholia.  With  it,  there  are  usually  combined 
constipation,  retardation  of  the  general  nutrition, 
insomnia,  and  sometimes  a  conscious  and  reasoning 
tendency  to  suicide  (suicidal  melancholia). 

The  delusional  form  of  sub-acute  melancholia 
may  appear  under  various  forms,  according  to  the 
nature  of  the  morbid  ideas.  The  principal  ones 
are:  hypochondriacal  melancholia  (nosomania  of 
the  older  writers)  characterized  by  unreasonable  ap- 
prehensions relative  to  the  health  and  to  the  func- 
tioning of  the  different  organs.  It  is  often  con- 
nected with  visceral  disorders,  of  which  it  is  then 
the  indirect  consequence.  Melancholia  with  ideas 
of  persecution^  characterized,,  as  its  name  indicates, 
by  varying  ideas  of  persecution,  unsystematized 
without  hallucinations,  and  which  must  not  be 
confounded  with  essential  insanity  of  persecution, 
which  will  be  described  later  on.  Religious  melan- 
cholia^ especially  common  at  puberty  and  at  the 
menopause  in  persons  of  piety,  which  is  essentially 
characterized  b}^  Scruples  of  conscience,  ideas  of  re- 
ligious culpability,  fear  of  damnation,  etc. 

Under  whatever  form  sub-acute  melancholia  may 
present  itself  its  essential  characteristic  is  the  lucidity 
of  the  patient,  often  accompanied  by  a  genuine  con- 
sciousness of  his  condition,  whence  the  name  of 
melancholia  with  consciousness  that  has  been  given 
it.     The  patients  are  capable  of  appreciating  their 


184  IVIELANCHOLIA  OR  LYPEMANIA. 

disorder  in  its  true  light  and,  sometimes  even,  of  re- 
sisting their  pathological  homicidal  or  suicidal  tend- 
encies. 

Cause.  Duration.  Terminatiox. —  Sub-acute 
melancholia  generally  manifests  itself  in  the  form  of 
more  or  less  lengthened  attacks,  l)eginning  and  end- 
ing suddenly,  and  ordinarily  occurring  several  times 
in  the  same  patient.  The  usual  termination  is 
therefore  in  recovery,  but  in  one  that  is  liable  to 
relapses.  In  some  cases  death  may  take  place, 
almost  always  by  suicide. 

Prognosis. — The  prognosis  is  more  grave  than 
that  of  acute  melancholia. 

Pathological  Anatomy. — The  lesions  are  varia- 
ble and  little  known;  the  same  fundamentally  as 
those  of  acute  melancholia. 

Diagnosis. — Sub-acute  melancholia,  especially  in 
its  delusional  form,  may  be  confounded  with  certain 
forms  of  partial  insanity,  notabl}'-  with  hypochondri- 
acal and  religious  insanity  and  insanity  of  persecu- 
tion. The  essential  elements  of  •  the  diagnosis  are : 
the  painful  nature  of  the  delusions,  the  fundamental 
general  depression  and  the  tendency  to  suicide  which 
are  wanting  in  partial  insanity.  We  will  point  out 
later  on  the  distinction  between  abonlic  melancholia 
and  aboulic  neurasthenia. 

Treatment. — ^The  treatment  is  the  same  as  for 
acute  melancholia.     Moral  treatment  is  especially  to 


HYPER-ACUTE  MELA^TCHOLIA.  185  . 

be  emphasized.  The  medication  should  be  suited 
to  the  case  when  the  disorder  is  symptomatic  of  a 
visceral  affection. 

i^III.     HYPER-ACUTE   MELANCHOLIA. 

(Melancholia  with  Stupor.) 

Stupor  has  been  placed  under  the  head  of  melan- 
cholia only  since  M.  Baillarger  demonstrated  that  it 
was  its  highest  expression ;  previously  it  was  regarded 
as  a  variety  of  dementia  (acute  dementia  of  Esquirol) . 
In  reality  it  may  be  considered  as  a  hyper-acute  mel- 
ancholia, that  is  to  say,  as  being  to  melancholia  what 
acute  delirium  is  to  mania. 

Etiology. — Stupor  generally  follows  an  acute 
melancholia  or  complicates  it.  It  is  especially  fre- 
quent in  the  different  stages  of  sexual  life ;  puberty, 
menstruation,  puerperal  condition,  menopause. 

Description. — In  a  psychic  point  of  view  we  dis- 
tinguish cases  where  the  patient  is  plunged  into  a 
veritable  stupor  (simple  stupor,  without  delusions, 
or  passive),  and  those  where  the  stupor  is  only  appar- 
ent and  masks  very  active  mental  workings.  In 
this  last  condition,  elucidated  by  Baillarger,  the 
patients  are  the  prey  of  the  most  terrible  delusions, 
of  terrifying  hallucinations,  they  assist  in  their  inter- 
nal consciousness  in  the  most  frightful  dramas  which 
have  nearly  always  for  their  themes,  massacres,  burn- 
ings, and  scenes  in  the  infernal  regions. 


186  MELAJSrCHOLIA  OR  LTPEMANIA. 

In  a  physical  point  of  view  the  depression  is  pushed 
to  the  extent  of  completely  abolishing  the  general 
activity  of  the  organism.  Every  effort  is  concen- 
trated in  the  mental  domain,  but  there  is  no  exter- 
nal manifestation,  and  nothing  of  that  which  is 
passing  in  the  thought  is  revealed  outside.  The 
patients  are  absolutely  inert  and  immobile ;  they  do 
not  talk,  walk,  eat  or  make  any  gesture  or  move- 
ment; their  limbs  are  semi-contracted,  and  retain 
the  position  in  which  they  are  put,  like  those  of  the 
cataleptics;  their  countenances  are  impassive  and 
present  the  mask  of  a  profound  hebetude ;  their  lips 
are  half  opened  and  dripping  saliva;  their  whole 
bodies,  and  especially  their  extremities,  are  cold  and 
bluish ;  anaesthesia  and  analgesia  are  complete ;  the 
bodily  temperature  is  lowered  several  degrees;  the 
pulse  is  very  slow,  the  sitiophobia  is  invincible,  and 
their  untidiness  is  absolute.  These  patients  remain 
in  this  condition  for  whole  months,  sometimes  in 
bed,  sometimes  erect,  or  sitting  in  some  corner  of  the 
ward  doubled  upon  themselves  with  the  immobility 
of  a  statue.  Occasionally,  under  the  influence  of  a 
sudden  impulse,  they  drop  all  at  once  their  torpor, 
have  a  sudden  spell  of  agitation,  or  commit  some  act 
of  violence,  then  everything  is  again  quiet  and  they 
fall  anew  into  their  inertia. 

The  majority  of  foreign  authors  recognize  and 
describe  under  tlie  name  of  attonitdt  and  of  kata- 
tonia  (Kahlbaum),  conditions  which  are  fundament- 
ally, as   Seglas   and   Chaslin  have   recently  demon- 


SFB- ACUTE    MELANCHOLIA.  187 

stated,  nothing  else  than  melancholia  with  stupor 
under  its  dijfferent  aspects,  and  in  which  predominate 
either  the  phenomena  of  hebetude,  or  spasmodic  and 
cataleptiform  symptoms. 

CouBSE.  DuRATiox.  TERMINATION. — Melan- 
cholia with  stupor  has  a  slow  chronic  course,  of 
variable  duration.  It  is  susceptible  of  cure  and  in 
this  case  the  patients  can  generally  recall  all  the 
phases  of  their  delirium ;  but  more  frequently  when 
the  affection  is  prolonged,  they  fall  into  cachexia 
and  marasmus  and  end  by  being  swept  away  by  the 
progress  of  the  physical  decay  or  by  some  complica- 
tion, such  as  passive  congestion  or  gangrene  of  the 
lungs. 

Pathological  Anatomy. — In  a  physiological 
point  of  view,  stupor  is,  according  to  M.  Ball,  a 
phenomenon  of  arrest.  As  to  the  anatomical  alter- 
ations to  which  it  is  connected,  mention  should  be 
made  of  oedema  of  the  brain,  that  has  been  claimed 
to  be  its  characteristic  lesion,  but  which  is  far  from 
being  constant,  and  of  an  atrojihy  of  the  convolutions 
that  has  been  observed  in  certain  cases. 

Treatment. — Is  the  same  as  that  for  acute  mel- 
ancholia. Tonics  and  general  excitants,  hydrother- 
apy and  electricity  are  to  be  insisted  upon.  Forced 
alimentation. 


188  MELANCHOLIA  OR  LTPEMANIA. 

iJR'.     CHRONIC  MELANCHOLIA. 

Chronic  melancholia  is,  as  we  have  seen,  one  of  the 
modes  of  termination  of  acute  melancholia.  It  may 
succeed  either  the  depressive  or  the  anxious  forms. 

In  the  first  case,  it  consists  in  the  persistence  in  an 
attenuated  form  of  the  psychic  and  bodily  symptoms 
of  acute  melancholia.  Xevertheless,  the  delusive 
ideas  become  gradually  modified  at  the  same  time  as 
they  take  on  a  special  fixedness.  They  are  ideas  of 
persecution  or  religious  delusions,  nearly  always  ac- 
companied with  multiple  hallucinations,  and  they 
form  a  sort  of  systematized  insanity,  differing  only 
from  true  progressive  systematized  delusions 
by  its  mode  of  beginning  and  evolution,  the  exist- 
ence of  a  certain  degree  of  general  depression  and 
the  return  at  irregular  intervals  of  melancholic  par- 
oxysms accompanied  with  suicidal  tendency  that 
recall  the  former  acute  attack.  This  is  what  is 
called,  very  accurately,  by  some  foreign  writers,  sec- 
ondary systematized  insanity  of  the  melancholic  type 
(paranoia  seconda.ria  melancholica) . 

Verj^  nearly  the  same  course  is  followed  in  chronic 
melancholia  consecutive  to  the  anxious  form.  Here, 
however,  the  delusions  take  on  a  special  character,  to 
which  attention  has  been  very  properly  called  by 
Ootard.  They  consist  in  absurd  hypochondriacal 
conceptions,  resembling  closely  the  hypochondriacal 
delusions  of  depressive  general  paralysis.  The 
patients     believe     themselves     dead,     decomposed, 


BEMITTENT  AND  INTEEMITTENT  MELANCHOLIA.    189 

choked  up,  annihilated.  Others  say  that  they 
have  neither  age,  sex,  nor  name,  that  they  do  not 
exist  and  that  nothing  exists  (insanity  of  negation  or 
enormity,  of  Cotard).  These  dehisions  finally  lead 
to  a  veritable  transformation  or  duplication  of  the 
personality  (Cotard,  Seglas). 

In  any  case  of  chronic  melancholia  we  may  see 
occur,  either  temporarily  or  permanently,  ideas  of 
grandeur,  the  existence  of  which  cannot  fail  to  com- 
plicate an  already  difficult  diagnosis.  Nevertheless, 
the  ideas  of  grandeur  may  manifest  themselves  in  an 
altogether  characteristic  melancholic  form.  The 
patient  will  say,  for  example,  not  that  he  possesses 
or  that  he  has  stolen,  but  that  he  owes  millions  and 
thousands  of  millions.  These  various  symptoms  of 
chronic  melancholia  and,  in  a  general  way,  of  the 
different  types  of  secondary  systematized  insanity 
have  not  yet  been  sufficiently^  studied. 

Chronic  melancholia  is  incurable.  It  may  continue 
indefinitely  and  finally  change  to  a  special  form  of 
dementia  (melancholic  dementia)  or  it  may  terminate, 
at  any  moment  during  its  course,  by  death  (suicide, 
chronic  visceral  disease,  acute  incidental  disorders). 

i^V.     REMITTENT    AND    INTERMITTENT    MELAN- 
CHOLIA. 

All  the  considerations  already  brought  forward  in 
regard  to  remittent  and  intermittent  mania  will, 
without  exception,  apply  to  remittent  and  intermit- 


190  MELANCHOLIA  OR  LTPEMANIA. 

tent   melancliolia.     It    is    therefore    unnecessary  to 
reproduce  them. 

We  will  confine  ourselves  to  the  statement  that 
cyclical  insanity  is  less  frequent  under  the  melan- 
cholic form,  and  that  when  it  does  exist  it  mani- 
fests itself  by  preference  in  the  acute  or  sub-acute 
form. 


Cbapter  m. 


INSANITY  OF    DOUBLE  FORM. 

(Circular  Insanity,  Delirium  of  Alternating  FormSy  Insanity 
of  Double  Phase.) 


Definition. — Insanity  of  double  form  is  a  gener- 
alized insanity,  characterized  by  the  regular  success- 
ion of  melancholico-maniacal  attacks,  that  is  to  say, 
of  attacks  made  up  of  a  period  of  melancholia  and  one 
of  mania,  or  vice  versa. 

Etiology — The  chief  cause  of  insanity  of  double 
form  is  heredity,  which  assumes  here  most  often  the 
similar  tj^Q.  Next  follow  the  other  physical  and 
moral  causes  of  insanity.  The  disorder  is  more  com- 
mon in  females  than  in  males.  It  usually  commences 
between  the  ages  of  20  and  30,  either  following  some 
accidental  cause  or  without  any  apparent  reason. 

Description — Insanity  of  double  form,  vaguely 
suspected  by  older  writers,  was  actually  discovered 
by  M.  Baillarger  and  by  Falret,  Sr.  M.  Ritti  gave  in 
1883  a  complete  and  very  excellent  description  of  it. 

In  order  to  make  ourselves  well  acquainted  with 
this  form,  we  must  study  successively :  (l)^he  com- 
position of  the  attacks ;  (2)  the  manner  in  which  they 
are  connected  one  with  another. 


192  INSANITY  OF  DOUBLE  FORM. 

(1).  The  attack  of  insanity  of  double  form  is  com- 
posed of  two  distinct  periods,  one  of  mania  the 
other  of  melancholia.  But  this  mania  and  this  melan- 
cholia are  not  conditions  special  to  circular  insanity ; 
they  are  nothing  but  simple  mania  and  melancholia, 
such  as  we  have  studied  in  the  foregoing  chapters. 
There  is,  therefore,  no  need  of  describing  here  a  spe- 
cial symptomatology  of  this  form ;  it  is  enough  to  state 
that  the  attack  which  composes  it  is  made  up  of  a 
period  of  mania  and  a  period  of  melancholia,  to  be 
acquainted  in  advance  with  all  the  symptoms. 

All  the  varieties  of  mania  and  melancholia  that 
have  been  passed  in  review  may  be  combined  to  make 
up  the  attack  of  insanity  of  double  form.  Thus  the 
attack  ma}^  be  formed  of  a  period  of  acute  mania 
and  one  of  melancholia  with  stupor,  of  a  period  of 
maniacal  excitation  and  one  of  melancholic  depres- 
sion, etc.,  etc.  We  repeat,  all  combinations  are  pos- 
sible, and  it  should  be  recognized  that  there  is  no 
necessary  relation  between  the  degree  of  intensity  of 
one  or  the  other  period.  Thus  a  period  of  slight 
maniacal  agitation  may  be  associated  with  one  of 
acute  melancholia  or  of  stupor  to  form  the  attack, 
and,  reciprocally,  a  period  of  simple  melancholic 
depression  may  be  combined  with  one  of  acute 
mania.  The  most  usual  constitution  of  the  at- 
tack, however,  is  the  union  of  a  period  of  more  or 
less  acute  maniacal  excitation  with  one  of  melan- 
cholic depression. 

An  important  point  to  know,  is  that  when  one  at- 


DESCRIPTION,  193 

tack  has  occurred,  it  is  usual  for  the  succeeding  ones 
to  resemble  it  in  all  particulars,  to  present  the  same 
symptomatic  physiognomy;  so  that  when  we  know 
one  attack  we  know  all. 

The  transition  from  one  period  to  another  is  not 
always  in  the  same  fashion.  Sometimes  the  change 
is  brusque,  instantaneous;  it  may  then  occur  even 
during  sleep,  so  that  the  patient  going  to  sleep  a 
maniac,  awakens  in  the  morning  a  melancholiac. 
This  is  often  the  case  in  double  form  insanity  of  very 
short  periods.  It  is  more  common,  however,  to  see 
the  passage  from  one  state  into  the  other  made  by 
insensible  gradations,  in  such  a  way  that  there  is  a 
moment  when  the  individual  seems  to  be  neither 
maniacal  nor  melancholic,  but  in  a  condition  of  per- 
fect equilibrium.  This  moment  of  equilibrium  has 
been,  from  the  first,  variously  interpreted.  Falret 
considered  it  a  true  intermission  of  short  duration, 
so  that,  in  his  opinion,  the  attack  was  made  up  of 
three  periods:  one  of  mania,  a  second  of  intermis- 
sion, and  the  third  of  melancholia.  Baillarger 
showed,  on  his  part,  that  the  moment  of  equilibrium 
is  not  an  intermission,  but  a  simple  instant,  difficult 
to  grasp,  traversed  without  stopping  by  the  patient 
in  passing  from  the  period  of  mania  to  that  of  mel- 
ancholia, and  that,  consequently,  these  two  con- 
ditions follow  each  other  without  interruption 
like  the  different  stages  of  intermittent  fever. 
This  is,  indeed,  what  usually  occurs;  but  the 
intermission   claimed   by   Falret    may  be   observed 

Ment.  Med.— 13. 


194  INSANITY  or  DOUBLE  FORM. 

in  certain  exceptional  cases.  Ritti  holds  that 
these  are  not  cases  of  insanity  of  double  form, 
but  alternating  attacks  of  periodic  mania  and  mel- 
ancholia (periodical  insanity  of  alternating  forms). 
A  last  mode  of  transition  by  successive  alternations 
consists  in  rapid  alternations  of  excitement  and  de- 
pression serving  as  an  intermediary  between  the  end 
of  one  period  and  the  commencement  of  the  other. 

Whatever  may  be  the  ^ay  in  which  the  periods 
succeed  each  other,  the  characteristic  mark  of  insan- 
ity of  double  form  is  the  striking  contrast  the 
patients  present  when  observed  in  one  period  or  the 
other.  In  their  condition  of  maniacal  excitation 
they  are  ^-^outhful  appearing,  full  in  liesh,  lively, 
vigorous,  alert,  the  face  is  animated,  the  complexion 
bright,  they  are  loquacious,  talkative,  turbulent  and 
constantly  in  action.  They  ai-e  prodigal,  spend- 
thrifts, vain,  false,  litigious,  passionate,  violent,  in- 
clined strongly  to  evil,  and  very  often  excessive  in 
alcohol  and  sexual  indulgence.  If  they  have  delu- 
sions, they  are  those  of  pride,  haughtiness,  ambition 
and  grandeur.  In  tlieir  stage  of  melancholic  de- 
pression they  are  so  different  from  the  above  that 
one  would  hardly  take  tliem  for  the  same  individuals. 
During  this  period  they  are  old  looking,  emaciated, 
broken  down,  wrinkled,  without  force  or  energy; 
their  countenance  is  downcast,  dull,  their  complexion 
pale ;  they  do  not  speak  or  move  but  pass  their  time 
lying  down  or  altogether  inactive.  They  are  avari- 
cious, economical  to  excess,  they  do  not  eat  or  drink 


JDB8CBIPTION . 


195 


or  have  any  sexual  desire,  they  show  themselves 
humble,  submissive,  without  volition,  obedient  and 
passive.  If  they  have  delusive  ideas,  they  are  those 
of  ruin  and  culpability  that  haunt  them,  and  these 
very  often  induce  refusal  of  food  and  suicide.  Even 
the  organic  functions  do  not  fail  to  suffer  in  these 
two  different  conditions,  and  the  pulse  which  is  active 
to  its  full  physiological  limits  in  the  period  of  mania, 
falls  to  40  or  50  pulsations  during  that  of  melan- 
cholia. 

The  same  is  true  in  regard  to  the  temperature,  the 
peripheral  circulation,  the  appetite,  the  secretions 
and  excretions,  which  exhibit  very  remarkable  differ- 
ences in  the  two  periods :  it  has  been  found  also  that 
the  bodily  weight  increases  during  the  period  of 
mania  to  fall  again  in  that  of  depression. 

This,  so  striking  a  contrast  presented  by  the 
patients,  is  in  reality  one  of  the  most  curious  and  in- 
teresting of  the  peculiarities  of  mental  medicine. 

(2).  The  constitution  of  the  attack  being  known 
it  remains  to  examine  how  the  different  attacks  suc- 
ceed each  other  in  series.  The  altogether  excep- 
tional cases  where  the  malady  includes  onl}?^  one 
attack  may  be  therefore  left  without  consideration. 

Two  cases  may  present  themselves.  Either  the 
attacks  may  follow  one  another  uniuterruptedh 
and  Avithout  being  separated  by  any  intermission, 
thus  constituting  continiioiis  insanity  of  double  form  ^ 
or  they  maj^  be  separated  from  each  other  by  a 
longer  or  shorter  intermission,  by  a  more  or  less  pro- 


196  INSAISITY  OF  DOUBLE  FORM. 

longed  return  to  the  normal  condition,  thus  consti- 
tuting intermittent  insanity  of  double  form  or  that 
made  up  of  separate  attacks.  Many  authors  also 
designate  the  first  of  these  circular  insanity  or 
the  insanity  of  double  form,  properly  speaking. 

There  are,  therefore,  only  these  two  yarieties  of 
double  form  insanity,  if  we  agree  Avith  M.  liitti 
that  the  periodical  insanity  of  alternating  forms  is 
not  to  be  included  under  this  head,  which  is  a  point 
open  to  question. 

Course.  Duration.  Termination. — The  course 
of  insauit^^  of  double  form  is  essentially  chronic  and 
intermittent,  or  rather  periodical. 

As  regards  its  duration,  we  must  consider  sepa- 
rately the  duration  of  the  attack  and  of  each  of  the 
periods  that  compose  it,  and  the  duration  of  the 
jualady  itself. 

The  attack  may  last  months  or  years,  or,  on  the 
other  hand,  it  may  be  limited  to  a  few  days.  The 
first  is,  however,  the  most  frequent;  the  attack  has 
usually  a  duration  of  six  months,  one  year,  or 
eighteen  months,  and  is  composed  of  a  period  of  ex- 
citement of  one  to  three  months  or  more,  and  a 
period  of  melancholia  generally  somewhat  longer. 
Although  the  attacks  have  nearly  always  the  same 
duration,  this  equality  is  only  approximate;  one  at- 
tack may  be  longer,  another  sliorter,  and  the  same, 
moreover,  is  the  case  with  the  periods  that  compose 
them.     Nevertheless,  we  may  say  that,  as  a  rule, 


COURSE.      DUBATIOX.     TERMINATION.  197 

they  have  the  same  general  character  and  the  same 
duration. 

In  the  second  case  the  attacks  last  a  day,  two 
days,  three  days,  and  so  on,  up  to  one  month.  Gen- 
erally, in  this  case,  the  periods  have  nearly  the  same 
duration  and  the  attacks  are  more  regular. 

The  duration  of  the  intermission  is  very  variable. 
It  is  in  double  form  insanity,  with  very  brief  attacks, 
that  it  is  most  often  lacking.  On  the  other  hand, 
it  is  almost  always  present  when  the  attacks  are 
of  long  duration.  It  may  have  a  duration  of  a 
few  days,  of  many  months,  and  even  of  several 
years. 

As  regards  the  duration  of  the  disorder  itself,  it 
is  very  long.  It  may  be  said,  even,  tliat  it  is  indef- 
inite, interminable,  since  with  the  alternations  once 
established,  the  patients  revolve  in  the  same  circle 
for  many  years,  and  generally  as  long  as  they 
survive. 

Insanity  of  double  form  may  end  in  recovery, 
a  termination  very  infrequent,  and  so  to  speak, 
exceptional.  It  usually  terminates  in  dementia,  but 
only  after  a  long  time,  as  the  patients  yield  very 
slowly  to  the  failure  of  the  intellect.  It  may  change 
into  some  other  form  of  insanity,  simple  mania  or 
melancholia,  for  example,  but  this  is  very  rarely 
the  case.  Finally,  it  may  terminate  by  death,  which 
occurs,  so  to  speak,  by  accident,  or  from  an  inter- 
current disease,  i.  e.,  from  suicide,  cerebral  congest- 
ion, epileptiform  attacks,  pneumonia,  etc.,  etc. 


198  HfSANITT  OF  DOUBLE  FORM. 

Pathological  Axatomy.  —  Except  in  cases 
where  the  patient  dies  of  apoplexy  and  there  is  found 
at  the  autopsy  an  evident  organic  alteration,  insanity 
of  double  form  has  no  peculiar  lesion.  On  the  con- 
trary, this  succession  of  two  opposed  conditions, 
mania  and  melancholia,  which  replace  each  other 
and  are  generally  followed  by  a  return  to  the  normal 
condition,  is  proof  enough  that  there  exist  only 
functional  disorders,  susceptible  not  only  of  disap- 
pearing, but  also  of  being  replaced  by  directly 
opposed  conditions.  It  is  probable  that  the  stage 
of  excitement  corresponds  to  a  cerebral  hyper- 
?emia,  and  that  of  depression  to  an  ischsemia, 
as  in  simple  mania  and  melancholia. 

Prognosis. — The  prognosis  of  insanity  of  double 
form  is  very  grave,  as  the  disorder  is,  like  most  of 
the  intermittent  or  periodical  insanities,  almost 
never  curable.  Falret,  Sr. ,  has  already  called  atten- 
tion to  the  noteworthy  peculiarity  that  double  form 
insanity,  which  is  made  up  of  tlie  two  most  curable 
forms  of  mental  disease,  mania  and  melancholia,  is 
itself  one  of  the  most  incurable. 

Diagnosis. — Taken  as  a  whole,  insanity  of  double 
form,  with  its  regular  succession  of  opposite  condi- 
tions, cannot  be  confounded  with  any  other.  Never- 
theless, when  the  stage  of  melancholic  depression  is 
but  slightly  marked,  it  may  happen  that  it  passes 
unrecognized,  and  the  malady  is  taken  for  a  chronic 
mania  of  the   remittent  or  intermittent  type,  all  the 


PEOGNOSIS.     DIAGNOSIS.  199 

more  probably,  since  in  these  the  attack  of  mania  is 
also  sometimes  succeeded  by  a  slight  depressive  re- 
action. 

It  very  often  happens  that  an  isolated  period  of 
double  form  insanity  is  mistaken  for  a  simple  attack 
of  mania  or  melancholia,  and  that  on  its  termination 
the  patient  is  considered  cured.  This  mistake  has 
been  often  made,  and,  notably,  by  M.  Baillarger 
himself.  It  is  in  consequence  of  the  fact  that  the 
mania  and  melancholia  of  insanity  of  double  form 
are  in  no  respects  different  from  simple  mania  and 
melancholia,  and  that,  taken  by  themselves  alone,  it 
is  impossible  to  distinguish  them.  All  that  can  be 
said,  is  that,  as  a  rule,  whenever  we  have  to  do  with 
an  attack  of  maniacal  excitation  we  ought  to  be  on 
our  guard,  and  make  sure  whether  it  is  not  due  to  a 
commencing  general  paralysis,  or  to  hysteria,  or  to 
insanity  of  double  form. 

It  may  be  mentioned  that  insanity  of  double  form 
may  be  confounded  in  its  maniacal  stage,  with  the 
prodromic  period  of  the  expansive  form  of  general 
paralysis.  This  error  is  the  more  possible  as  the 
excitement  may  cause  the  appearance  in  insanity  of 
double  form,  of  certain  congestive  phenomena  such 
as  pupillary  inequality,  tremor,  hesitation  of  speech, 
which  complicate  the  diagnosis.  The  distinction  is 
established  by  the  fact  that  in  general  paralysis, 
even  in  its  beginning,  the  ideas  have  a  stamp  of  de- 
mentia that  is  lacking  in  double  form  insanity,  and, 
further,  by  the  fact  that  in  the  excited  stages  of  cir- 


200  INSANITY  OF  DOUBLE  FOEM. 

cular  insanity,  the  patients  are  thoroii'glily  vicious  and 
malevolent,  while  the  expansive  general  paralytics 
are,  at  least  in  appearance,  generous  and  benevolent. 
Insanity  of  double  form  once  recognized,  it  still 
remains  to  be  determined  whether  it  is  simple^  which 
is  usually  the  case,  or  whether  it  is  connected  with 
some  other  morbid  condition.  If  the  latter,  it  is 
almost  always  with  general  paralysis  (circular  gen- 
eral paralysis  or  paresis  of  double  form),  epilepsy, 
or  hysteria. 

Treatmeis^t. — Sulphate  of  quinine  in  large  doses, 
30  or  40  centigrams  to  2  grams  per  diem,  has  been 
recommended  for  this  disease,  principally  on  account 
of  its  periodic  character.  Bromide  of  potash  and 
hypodermic  injections  of  opium  and  morphine  have 
likewise  been  employed.  The  treatment  of  the  at- 
tacks and  that  of  each  period  call  for  the  ordinary 
means  used  in  attacks  of  mania  and  melancholia. 
Dr.  Hurd  has  recommended  hyoscyamine  in  the  ex- 
cited periods,  and  codeine  and  citrate  of  caffeine  in 
those  of  depression.  Sequestration  of  the  patient  is 
especially  demanded  during  the  period  of  excite- 
ment, the  patients  being  then  habitually  dangerous. 
It  is  less  necessary  during  the  periods  of  melancholia, 
especially  when  the  depression  is  not  very  great. 


APPENDIX. 

The    Graphic    Repkesentation  of   Generalized 
Insanities. 

In  order  to  fiiruish  a  clearer  idea  of  the  many 
special  points  relative  to  the  constitution  and  the 
course  of  the  generalized  insanities,  it  seems  to  me 
to  be  of  utility  to  represent  them  here  in  a  graphic 
form,  by  the  aid  of  a  diagram  specially  devised  for 
the  purpose. 

This  form,  which  I  presented  to  the  Soci6t6  Med- 
ico-psychologique  in  1883,  and  which  I  have  con- 
stantly used  since  then,  in  my  free  instruction  in  the 
medical  school  at  Bordeaux,  is  composed  essentially 
of  a  dotted  horizontal  line  representing  the  normal 
condition.  Above  this  diverge,  according  to  their 
intensity,  the  lines  representing  the  various  types 
of  excitement  or  mania ;  below,  in  an  inverse  order, 
those  of  the  different  types  of  depression  or  lype- 
mania.  The  schematic  diagram  thus  formed  is  cut 
by  vertical  lines  indicating,  as  in  the  temperature 
diagrams,  the  division  into  days. 

With  this  very  simple  diagram  we  can  reproduce 
exactly,  and  in  their  minutest  traits,  the  types  of 
generalized  insanity  we  have  passed  in  review. 

For  instance,  we  have  in  figure  1  an  attack  of 
acute  mania.     We  see  represented  there: 


20*2  GENERALIZED  INSANITIES. 

(1).  The  initial  period  (AB)  characterized  lirst 
by  depressiou,  then  by  progressive  excitement  which 
may  reach  its  apogee  either  suddenly  or  very  grad- 
ually, or,  as  here  indicated,  by  a  series  of  gradual 
oscillations. 

(2).  The  period  of  full  development  {perioife 
<r  etat)  (BC),  or  that  of  the  attack,  properly 
speaking,  characterized  by  the  acute  evolution  of 
the  excitement  with  more  or  less  marked  variations. 

(3) .  The  period  of  termination  (C  D) ,  which  in  the 
case  of  recovery,  here  selected,  is  characterized  by  a 
return,  either  sudden,  by  oscillations,  or  by  insen- 
sible transitions,  to  the  normal  condition. 

It  will  be  readily  seen  that  an  attack  of  sub-acute 
or  hyperacute  mania,  as  well  as  any  variety  of  mel- 
ancholia, with  their  special  variations  of  beginning, 
intensity,  evolution,  and  termination,  can  also  be  thus 
represented. 

Figure  2  represents  remittent  mania.  This  vari- 
ety of  insanity  is  constituted,  as  we  are  aware,  by 
the  more  or  less  regular  return  of  acute  crises  or 
paroxysms  of  mania,  separated  by  periods  of 
attenuation  or  remission.  Here  is  seen,  in  the 
clearest  manner,  this  succession  of  phenomena. 
ABCD  gives  us  the  curve  of  the  acute  attack 
with  its  three  periods  of  onset,  culmination,  and 
decline;  DA  shoAvs  the  remission,  its  intensity, 
and  duration;  then  a  new  exacerbation  ABCD  is 
produced,  followed  by  a  new  remission,  and  so  on 
indefinitely. 


GENERALIZED  INSANITIES.  203 

Instead  of  remittent  niaiiia  we  may  take  for  our 
tracing  remittent  lypemania,  which  will  not  require 
further  explanation. 

Figure  3  represents  intermittent  nianin.  This 
\'arietj  of  insanity  is  formed,  as  we  are  aware,  by  a 
succession  of  maniacal  attacks  separated  from  each 
other,  not  by  phases  of  attenuation  like  remittent 
mania,  but  by  complete  returns  to  the  normal  con- 
dition, or  intermissions.  A  B  C  D  figures  the  attack, 
with  its  initial  period,  its  sudden  termination,  and 
its  period  of  culmination ;  D  A  is  the  return  to  the 
normal  condition,  a  true  recovery,  as  is  seen,  diiiei-- 
ing  only  from  an  absolute  recovery  in  that  it  is 
intermediate  between  two  attacks.  Following  it,  in 
fact,  we  see  a  new  attack  A  B  C  D  produced,  alto- 
gether identical  with  the  former  one,  then  a  new 
intermission,  and  so  on. 

Figures  4,  5  and  6,  are  devoted  lo  the  representa- 
tion of  insanity  of  double  form.  In  figure  4,  we  have 
continuous  double  form  or  circular  insanity  in  which 
the  attacks  of  insanity  are  connected  end  to  end  and 
follow  each  other  without  interruption.  ABCDA 
represents  the  complete  attack  of  double  form  in- 
sanity, in  which  we  see  the  sudden  beginning  of  the 
phase  of  excitement  (AB) ;  its  period  of  full  develop- 
ment (B  C) ;  the  instantaneous  passage  of  the  phase 
of  excitement  into  that  of  depression  (( '  D) ;  the 
period  of  full  development  of  tlie  |)haso  of  depres- 
sion (D  A) ;  the  sudden  passage  from  the  ]")hase  of 
depression   to  that  of    excitement    (AB).     Then    ;i. 


204  GENERALIZED  INSANITIES. 

new  attack  like  in  all  points  to  the  former  one, 
etc.,  etc. 

In  figure  5,  we  see  figured  the  curve  of  intermittent 
double  form  insanity  or  that  Avith  separated  attacks,  in 
which  the  attacks,  instead  of  succeeding  each  other 
uninterruptedly  are  separated  by  longer  or  shorter  re- 
turns to  the  normal  condition.  A  B  C  D  E  F  here  re- 
presents the  complete  attack :  the  onset  of  the  stage  of 
excitement  by  gradual  oscillations  (A  B) ;  the  period 
of  full  development  (B  C) ;  the  passage  by  gradual 
oscillations  to  the  phase  of  depression (C  D) ;  the  cul- 
mination of  this  phase  (D  E) ;  and  the  rapid  return 
to  the  normal  (E  F) .  This  normal  interval  is  figured 
in  FA.  Then  follows  a  new  attack  A  B  C  D  E  F 
with  the  same  features  as  the  first  and  followed,  like 
it,  by  another  return  to  the  normal  condition  F  A, 
etc.,  etc. 

In  figure  6,  we  have  what  M.  Ritti  calls  periodi- 
cal insanity  of  alternating  forms,  and  which  he  con- 
siders as  the  combination  in  the  same  individual  of 
an  inteiTuittent  mania  and  an  intermittent  melancho- 
lia, while,  according  to  other  authorities,  it  is  a  third 
variety  of  insanity  of  double  form  in  which  an  inter- 
mission or  return  to  the  normal  occurs,  not  only  after 
each  complete  attack,  as  in  the  proceeding  form,  but 
also  after  eacl)  phase  of  the  attack.  Whichever 
theoretical  conception  is  adopted,  this  variety  of 
mental  disease  is  none  the  less  exactly  represented 
here.  A  B  C  D  is  the  maniacal  phase ;  D  E  the  con- 
secutive normal  condition;  EFGH  the  melancholic 


GENERALIZED  INSANITIES.  205 

phase ;  H  A  the  second  return  to  the  normal.  Then 
the  same  cycle  is  repeated  anew  under  the  same 
conditions. 

It  will  be  noticed  how  all  the  technical  considera- 
tions relative  to  the  different  forms  of  generalized 
insanity  are  simplified  and  cleared  up,  thanks  to 
these  diagrams.  By  their  means  it  is  likewise  easy 
to  apprehend  and  appreciate  with  a  rapid  glance  the 
differences,  so  important  in  a  medico-legal  point  of 
view,  that  exist  between  the  various  states  of  lucid- 
ity or  lucid  intervals ;  the  lucid  moment,  which  is  a 
transitory  return  to  the  normal  condition  during  an 
attack :  the  re^nission,  which  is  a  simple  attenuation 
of  the  symptoms  of  the  attack;  the  i7iter mission  or 
inter mittence,  which  is  a  true  recovery  between  two 
attacks. 

The  utility  of  the  diagrams  is  not  shoAvn  merely 
in  a  theoretic  point  of  view  and  in  figuring  schemat- 
ically the  diverse  forms  of  generalized  insanity. 
They  may  also  be  clinically  useful  as  a  record  on 
which  to  inscribe  from  day  to  day  the  state  of 
patients,  permitting  us  thus  to  obtain  faithful 
tracings  of  the  attacks  that  are  eminently  suggestive. 
I  have  adapted  it  to  this  use  by  a  very  easily  made 
addition  of  horizontal  lines  for  the  record  of  the 
curves  of  the  pulse,  the  temperature,  and  the  respi- 
ration,  together  with  that  of  the  attack  itself. 


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Cbapter  IDIFIT, 

PARTIAL  OR  ESSENTIAL  INSANITIES. 
§  I.     GENERAL  REMARKS. 

We  are  already  acquainted  with  the  principal 
differential  characters  of  the  generalized  and  the 
partial  insanities.  We  are  aware  that  the  first  are 
accompanied  with  a  morbid  reaction  of  the  general 
activity,  excitement  or  depression;  that  they  are 
often  curable ;  and  that  they  form,  by  their  associa- 
tion with  other  physiological  or  pathological  condi- 
tions, the  symptomatic  insanities.  We  also  know 
that  the  partial  insanities  are  not  accompanied 
by  any  permanent  morMd  reaction,  that  they  are 
seldom  curable,  finally  that  they  are  idiopathic  or 
essential,  that  is  to  say,  independent  and  autonomous. 

When  viewed  in  respect  to  the  form  of  their  de- 
lusions, the  partial  insanities  are  relatively  numerous : 
the}^  comprise  in  fact,  hypochondriacal  insanity,  in- 
sanity of  persecution,  religious,  political,  jealous, 
erotic,  ambitious,  etc.,  insanities.  But  as  we  have 
seen  in  the  chapter  on  classification,  all  these  names 
do  not,  properly  speaking,  represent  distinct  entities; 
they  are  varieties  or  rather  phases  of  one  and  the 
same  disease. 

The  patient  passes  first  through  a  state  of  painful 


GENERAL  REMARKS.  213 

disquietude,  during  which  he  has  strauge  feelings 
and  believes  his  relations  with  the  external  world 
have  been  modified,  he  falls  back  on  himself  and 
busies  himself  in  painful  self  analysis.  With  a 
mental  acuteness,  the  more  pronounced  since  all  his 
faculties  are  concentrated  on  one  object,  he  scrutin- 
izes closely  all  he  says  and  does  and  all  that  goes  on 
around  him,  and  he  finds  in  everything,  by  a  course 
of  reasoning  more  or  less  logical,  some  hidden  mean- 
ing, some  reference  to  his  person  or  his  situation. 
This  is  the  hypochondriacal  stage  of  Morel,  the  period 
of  inquietude  of  Magnan,  which  I  myself  have 
called  the  period  of  analytic  concentration  or  of 
subjective  analysis,  on  account  of  the  tendency  to 
inductive  analysis  predominating  for  the  time  in  the 
patient.  Hallucinations  may  also  occur,  but  it  is  in 
the  succeeding  period  that  we  meet  with  them  almost 
invariably. 

In  this  second  period,  the  patient  imagines  a  ra- 
tional explanation  of  his  sufferings,  of  his  inquie- 
tude and  of  the  attentions  of  which  he  believes 
himself  to  be  the  object;  he  finds,  as  it  has  been 
happily  expressed,  Xhefor'inula  of  his  delusion.  If, 
as  he  thinks,  disturbing  incidents  multiply  about 
him;  if  he  hears  voices  insulting  him  and  answering 
his  most  secret  thoughts ;  if  he  smells  noisome  odors ; 
if  he  experiences  m  his  body  veritable  electric  shocks ; 
it  is  because  he  is  the  object  of  the  malevolence  and 
animosity  of  mankind,  and  of  certain  persons  in 
particular.      Powerful    enemies,   bent  on  his   ruin, 


214  PARTIAL  OR  ESSENTIAL  INSANITIES. 

liave  organized  a  conspiracy  against  him,  and  have 
employed  for  his  injuiy  various  mysterious  agencies, 
such  as  magnetism,  electricity,  the  telephone,  etc. 
This  is  the  insanity  of  persecution  discovered  by 
Lasegue,  who  has  given  of  it  a  masterly  description. 
Once  implanted  in  the  mind  of  the  patient,  the  delu- 
sions gradually  assume  shape  and  become  elaborated, 
and  come  by  insensible  degrees  to  form  an  unvarying 
theme,  a  romance  of  which  the  patient  is  at  once  the 
author  and  the  hero.  This  second  phase  well  merits, 
as  we  see,  the  name  of  period  of  delusive  expUcatio7i. 

After  a  longer  or  shorter  period,  sometimes  not 
for  many  years,  an  important  change  occurs  in  the 
condition  of  the  patient,  who,  from  being  a  subject 
of  persecution,  becomes  ambitious  or,  as  it  is  called, 
a  megalomaniac.  There  is  here  not  merely  a  change 
<^)f  delusions,  a  new  explanation  substituted  for  the 
former  one;  the  whole  personality  of  the  patient  is 
transformed:  he  is  a  prince,  king,  prophet,  or  even 
Deity  himself.  Thus  appear  ambitious  ideas,  join- 
ing themselves  to  those  of  persecution  not  by  simpk' 
association,  Tiut  in  a  most  intimate  combination,  in 
such  a  way  as  to  form  a  peifecth^  homogeneous 
whole  in  which  the  two  delusional  elements  enter  in 
varying  degree  according  to  the  case.  From  this  on 
the  23atient  remains  permanently  incrusted  in  this 
condition  which  persists,  it  may  be  said,  till  his 
death.  It  is  the  third  and  last  stage,  or  stage  of 
transformation  of  the  personality . 

As  regards  the  fourth  period,    admitted   by   M. 


GENERAL  REMARKS.  215 

Magnan  under  the  name  of  the  period  of  dementia, 
it  is  not,  in  reality,  a  phase  of  the  disease,  but  only 
one  of  its  modes  of  termination,  as  it  is  of  other 
forms  of  mental  alienation.  Many  of  the  partially 
insane  never  reach  dementia,  properly  so  called,  and 
even  when  their  intellect  does  gradually  become  en- 
feebled, their  delusions  still  survive  in  their  essential 
characters. 

This  conception  of  the  typical  partial  insanity  is 
very  correct  and  corresponds,  save  in  exceptional 
cases  of  which  we  shall  speak  later  on,  to  the  actual 
facts.  But  there  is  more:  the  other  partial  insani- 
ties, whose  existence  has  been  mentioned,  may  also 
fall  into  this  synthetic  class.  Thus  religious  in- 
sanity is  not,  when  closely  regarded,  a  species  by 
itself,  but  simply  a  variety  of  delusive  explanation 
made  during  insanity  of  persecution.  The  same  is 
true    of     erotic,     political,     jealous    insanity,     etc. 

The  patients  in  whom  we  observe  these  symptoms 
begin  with  a  period  of  inquietude  or  of  subjective 
analysis  altogether  analogous  to  that  preceding  de- 
lusions of  persecution.  It  is  only  when  they  en- 
deavor to  explain  to  themselves  their  discomforts 
that  they  are  separated;  some  find  it  in  celestial  or 
diabolic  intervention  (religious  delusions),  others  in 
the  love  of  some  ideal  or  earthly  beauty  (erotic  in- 
sanity), and  still  others  in  the  intrigues  of  dynastic 
parties  (political  insanity),  or  of  enemies  of  their 
conjugal  happiness  (delusions  of  jealousy) ,  All  these 
delusional    conditions,    and    other    analogous    ones, 


216  PARTIAL  OR  ESSENTIAL  INSANITIES. 

when  they  exist,  are  therefore  only  simple  varieties 
of  the  delusive  explanation  of  partial  insanity,  differ- 
ent statements  of  one  formula,  and  therefore  pertain 
to  the  same  disease.  As  evidence  of  this,  they  are 
very  often  associated  with  delusions  of  persecution, 
and  it  is  not  rare  to  see  patients  in  these  patholog- 
ical conditions,  with  religious,  erotic,  political,  and 
even  jealous  delusions,  all  revolving  around  persecu- 
tory delusions  as  a  common  centre.  A  still  further 
proof  is  that  all  these  delusions,  have  the  same 
point  of  departure,  a  phase  of  hypochondria  or  of 
subjective  analysis,  and  also,  in  the  same  way,  the 
transformation  of  the  personality  or  megalomania. 

The  partial  insanities,  actually  known,  form  there- 
fore one  and  the  same  vesania,  which,  in  its  normal 
form  presents  a  typical  evolution  in  three  periods: 
(1)  a  period  of  inquietude  or  of  subjective  analysis 
(hypochondriacal  insanity) ;  (2)  a  period  of  delu- 
sional explanation  (persecutory,  religious,  erotic,  po- 
litical, jealous  delusions,  etc). ;  (3)  a  period  of  trans- 
formation of  the  personality  (grand  delirium).  We 
denominate  it  for  this  reason,  progressive  systema- 
tized insanity.  Progressive  systematic  psychosis 
(Garnier).  Chronic  progressive  systematic  psychosis 
(Ballet).  Chronic  delirium  (Magnan).  Paranoia 
primaria  (Italian).    Primary  Verrilcktheit  (German). 

A  long  discussion  took  place  within  a  few  years 
in  the  Medico-psychological  society  of  Paris  on  the 
subject  of  partial  insanities.  Some,  with  Magnan, 
recognized  two  forms  of  systematized  insanity  or,  as 


GENEEAL   REMARKS.  217 

they  improperly  name  it,  chronic  delirium:  (1)  sys- 
tematized progressive  insanity  evolving  always  in 
distinct  periods;  (2)  systematized  insanity  of  de- 
generacy, irregular  and  atypical.  Others,  with  M. 
Ball,  deny  the  distinct  existence  of  a  systematized 
insanity  of  degeneracy,  and  hold  that  systematized 
insanity,  progressive  itself,  has  always  the  path- 
ognomonic evolution  attributed  to  it.  An  agree- 
ment between  the  two  sides  was  not  reached. 

At  base  these  two  views  have  each  their  share  of 
truth,  and  it  may  be  admitted  that  there  is  a  typical 
systematized  insanity  characterized  by  an  habitual 
evolution  in  three  periods,  with  abnormal  forms,  the 
principal  one  of  which  is  that  met  with  in  cases  of 
degeneracy. 

Moreover,  this  view  of  the  subject  is  not  new  nor 
special  to  France,  as  it  has  been  given  long  since  in 
the  majority  of  foreign  works.  The  Italians, 
especially,  who  include  all  the  systematized  insanities 
under  the  generic  name  of  paranoia,  divide  them 
into  two  very  distinct  species :  (1)  degenerative  para- 
noia, original  or  late,  according  to  the  epoch  of  its 
appearance ;  [^)  psycho -neurotic  paranoia,  primary  or 
secondary,  according  as  it  shows  itself  at  once  or 
succeeds  a  generalized  insanity.  This  semeiological 
grouping  of  systematized  insanities  corresponds,  it 
will  be  seen,  to  the  division  proposed  in  France :  it 
is  even  more  complete.  The  Italians  have  gone  so 
far  as  to  formulate  an  original  theory  to  explain 
how  systematized  insanity  may  be  primary  in  some 

Ment.  Med.— 14. 


218  PARTIAL  OR  ESSENTIAL  INSANITIES. 

subjects  and  secondary  in  others.  They  pretend,  in 
fact,  that  systematized  insanity  is  always  consecu- 
tive to  a  generalized  insanity,  of  which  it  forms  a 
more  advanced  stage ;  when  it  appears  primarily  in 
an  individual  it  succeeds  a  generalized  insanity  in 
his  ancestors ;  when  it  is  secondary  the  succession  is 
confined  to  the  one  individual. 

We  have  to  take  up  here  only  primary  systema- 
tized insanity  (paranoia  primaria),  as  we  have 
already  spoken  of  secondary  systematized  insanity 
(paranoia  secondaria)  in  the  chapters  on  mania  and 
melancholia.  As  to  the  systematized  insanity  of 
degeneracy  (paranoia  degenerativa) ,  it  will  find  its 
natural  place  in  the  descriptions  of  the  mental  con- 
ditions of  degeneracy. 

^11.     PROGRESSIVE  SYSTEMATIZED  INSANITY. 

Definition. — Progressive  systematized  insanity 
may  be  defined  as:  a  chronic,  essential  insanity, 
without  disorder  of  the  general  activity,  character- 
ized by  hallucinations,  especially  of  liearing,  by  de- 
lusions tending  to  become  systematized,  and  ending 
in  a  transformation  of  the  personality. 

Etiology. — Systematized  insanity,  we  have  said, 
constitutes  the  essential  insanity,  the  true  insanity. 
Its  etiology  is  also  rather  limited.  In  it,  accessory 
causes  hardly  come  in  play,  it  is  an  integrant  part 
of  the  individual.  The  patients  receive  its  germ  at 
birth  and  it  develops  at  its  appointed  hour  under  the 


PROGRESSIVE  SYSTEMATIZED  INSANITY.  219 

influence  of  the  slightest  cause,  for  example,  poverty, 
difficulties  of  social  life,  disappointments,  mortifica- 
tions, conjugal  unhappiness,  the  menopause,  etc., 
etc.  That  is  to  say,  that  tlic  principal  cause  of 
partial  insanity  is  heredity.  It  is  well  known  that 
it  is  more  frequent  in  females,  celibates,  and  espe- 
cially in  those  born  out  of  wedlock.  It  affects,  by 
preference,  those  of  a  gloomy,  suspicious,  irritable 
character,  and  inclined  to  pride  and  misanthropy. 

1. — Period  of  Subjectfv^e  Analysis. 
Hypochondriacal  Iifisamity . 

The  disorder  begins,  most  frequently,  with  un- 
comfortable sensations,  functional  or  organic  dis- 
turbances, which  commence  by  startling  the  patient, 
attracting  his  attention  and  leading  him  to  analyze 
them.  These  are  uncomfortable  sensations,  for 
example,  headaches,  palpitations,  buzzing  in  the 
ears,  and  dazzling  the  eyes.  Still  more  often  they 
are  vague  uneasinesses  located  usually  in  the  genital 
organs  or  the  digestive  tract.  Sometimes  also  there 
are  abnormal  sensations  of  cranial  constriction,  of 
emptiness  of  the  skull,  with  difficulty  of  working, 
thinking,  etc.  The  patient  is  unduly  disturbed  by 
tliese  symptoms,  he  studies  himself,  thinks  over  all 
his  feelings  and  finds  them  increasing.  What  ap- 
pears to  him  most  strange  is  that,  besides  the  bodily 
symptoms  he  experiences,  he  thinks  his  intelligence 
is  being  overturned ;  his  mind  acts  without  his  voli- 


220  PARTIAL  OR  ESSENTIAL  INSANITIES. 

tion,  he  canuot  control  it,  aud  this  automatic  part  of 
liis  being  may  sometimes  become  so  powerful  tliat 
his  thoughts  exteriorize  themselves  and  become  more 
or  less  consciously  acted  out.  There  are  here,  as 
M.  Seglas  has  demonstrated,  actual  psycho-motor 
hallucinations,  which  are,  in  spite  of  the  received 
opinion,  among  the  first  symptoms  observed  in  these 
})atients. 

Thus  far  the  future  paranoiac  resembles  more  or 
less  strongly  a  simple  hypochondriac,  for  which, 
moreover,  lie  may  be  mistaken;  but  soon,  by  a 
natural  mental  tendency  in  which  he  is  unlike  all  other 
lunatics,  he  begins  to  search  for  a  cause  of  his 
troubles,  not  in  himself,  but  externally.  This  is,  it 
may  be  said,  the  first  step  of  his  psychic  evolution, 
M'hich  maj''  in  some  cases  be  manifested  at  once 
without  any  preceding  hypochondria. 

From  this  time  on  the  patient  extends  his  investi- 
gation to  his  surroundings,  and  refers  to  himself 
every  thing  that  he  hears  or  sees  around  him  [aufo- 
philia  of  Ball).  It  seems  to  him  that  persons  and 
things  are  altered,  that  people  look  at  him,  make 
signs  and  whisper  when  he  passes;  everything  said 
has  a  double  meaning,  he  cannot  find  things  in  their 
yjlaces ;  he  is  unable  to  work ;  his  business  goes  wrong ; 
jiothing  succeeds  with    hini. 

Always  keeping  to  himself  the  result  of  his 
thoughts,  he  becomes  more  and  more  gloomy  and 
sometimes  feels  even  driven  to  suicide ;  but  these  are 
only  temporary  discouragements  to  which  the  para- 


PROGRESSIVE  SYSTEMATIZED  INSAXITY.  221 

uoiac  rarely  succumbs;  he  usually  resists  them, 
accepts  the  battle  against  fate,  seeks  to  find  out 
more,  and  becomes  more  and  more  wrapped  up  in 
his  morbid  investigations. 

Reviewing  his  whole  former  life,  he  finds  trivial 
incidents  that  seem  to  him  significant,  and,  which, 
taken  together,  convince  him  that  he  has  long  been 
the  object  of  a  hidden  animosity. 
.  By  this  time,  hoAvever,  sensory  disorders  have 
made  their  appearance,  if  indeed  they  have  not  all 
along  existed.  Sometimes  they  are  false  auditory 
sensations,  plaintive  cries,  sound  of  bells,  detonations, 
confused  voices,  repetition  of  his  thoughts;  some- 
times they  are  false  olfactory  or  gustatory  sensations ; 
and  again,  various  disorders  of  the  tactile  or  genital 
senses. 

With  these  new  elements  in  operation,  the  delus- 
ions make  rapid  progress,  and  the  second  period  of 
the  disorder  soon  appears. 

2. — Period  of  Delusional  Explanation. 

{Insanity  of  Persecution.    Lasegiie's  Disease.) 

This  type  of  insanity,  first  studied  in  1852  by 
Lasegue,  whose  description  is  still  authoritative, 
consists  essentially  in  the  development  and  progressive 
systematization  of  the  tendency  of  the  patient  to  refer 
everything  to  the  hostility  and  malevolence  of  others. 
Although  its  symptoms  are  far  from  being  absolutely 
identical  in  all  cases,  the  following  is  the  usual 
course  of  the  disorder, 


222  PARTIAL  OR  ESSENTIAL  INSANITIES. 

At  first  the  delusions  are  confused.  The  patients 
believe  that  there  is  ill  will  toward  them,  that  is  all. 
They  do  not  know  by  whom  nor  why  nor  how. 
They^  is  their  habitual  expression.  ''  They  wish  me 
ill,  they  insult  me,  they  trouble  me,  electrify,  poison, 
violate,  throw  bad  smells  on  me,"  they  say.  Then, 
some  quickly,  others  more  slowly,  select  in  their  past 
life,  their  customary  occupations  or  their  mode  of 
living,  some  special  fact  that  draws  their  attention 
to  such  and  such  a  group  of  persons,  or  even  to  a 
single  individual.  Some,  according  as  they  have 
previously  had  their  attention  drawn  to  the  idea  of 
the  police,  free  masonry,  the  Jesuits,  etc.,  attribute 
what  they  call  their  troubles  to  the  police,  free 
masons,  and  Jesuits.  Others,  who  have  already  en- 
emies or  simph^  those  whom  they  distrust,  make 
them  the  responsible  authors  of  all  the  evil  that 
happens  to  them.  A  conspiracy  has  been  made 
against  them,  they  say,  into  which  have  entered 
neighbors,  servants,  relatives,  friends,  frequently 
also  unknown  individuals ;  sometimes  a  whole  town 
is  moved  against  them,  and  the  patients  believe 
everything  they  see  or  hear  is  directed  against  thera ; 
they  interpret  everything  according  to  their  morbid 
ideas.  In  this  is  the  first  step  toward  the  organiza- 
tion of  the  delusions.  As  regards  the  explanation 
of  the  proceedings  of  their  so-called  enemies,  it  is  at 
base  almost  invariably  the  same.  In  the  presence 
of  phenomena  for  which  they  can  not  give  a  natural 
interpretation,  the  patients  seek  to  account  for  them 


PROGEESSIVE  SYSTEMATIZED  INSAJNTITY.  223 

by  the  most  extraordinary  ways.  Holes  are  made 
in  the  wall  to  speak  to  them,  to  address  insults  to 
them,  to  blow  irritating  powders  and  evil  odors 
through,  to  electrify  them ;  electric  batteries  are  put 
up  in  their  vicinity,  or  even  in  their  chambers,  also 
acoustic  tubes  and  telephones,  with  the  aid  of  which 
their  enemies  insult  them  and  produce  in  them  all 
kinds  of  disagreeable  sensations. 

During  this  time  the  hallucinations  multiply;  if 
heretofore  they  were  psychic  or  psycho-motor,  they 
now  become  fully  psycho-sensorial.  The  voices  are 
clear,  plainly  insulting;  they  are  heard  not  only  at 
night  and  at  intervals,  as  in  the  beginning,  but  also 
during  the  day  and  almost  uninterruptedly,  some- 
times in  only  one  ear  (unilateral  hallucinations) ,  gen- 
erally in  both ;  they  use  coarse  language,  injurious  epi- 
thets, slang,  and  whole  sentences  in  which  accusations, 
insults  and  threats  predominate.  Very  often  at  this 
time,  sometimes  even  from  the  beginning,  as  we 
have  seen,  there  occurs  a  curious  hallucinatory  phe- 
nomenon, the  echo  of  the  thoughts.  The  patient 
hears  his  thought  distinctly  uttered  as  soon  as  it 
arises,  not  in  a  loud  tone,  but  in  a  sort  of  more  or 
less  variable  internal  voice :  and  he  then  believes  that 
others  also  hear  them  which  is  to  him  an  inexpress- 
ible torture,  since  the  thoughts  he  most  desires  to 
keep  secret  are  those  most  distinctly  heard.  He 
perceives  that  others  hear  his  thoughts  since  they 
respond  before  he  has  uttered  them,  and  because  he 
hears  mentioned  facts  of  his  past  life  which  were 


224  PAHTIAi  OK  ESSENTIAL  INSANITIES. 

only  known  to  himself,  etc.,  etc.  This  phenome- 
non, so  marvelous  to  him,  he  explains  by  the  inter- 
vention of  electricity,  the  telephone,  or  phonograph ; 
sometimes  he  comes  to  imagine  that  this  voice  that 
he  hears  in  him  belongs  to  another  individual,  and 
this  I  believe  to  be  the  usual  starting  point  of  that 
curious  pathological  condition  known  as  duplication 
of  the  personality. 

In  reality  the  echo  of  the  thought  is  only  a  path- 
ological manifestation  of  that  which  psychologists 
have  called  animated  internal  speech  (Egger, 
Strieker),  Ballet,  motor  representation  of  articula- 
tion^ and  finally  that  called  by  Seglas  verbal  psycho- 
motor hallucination.  The  patients  unconsciously 
form  in  speech  their  thoughts,  and  sonle  (Regis, 
Seglas) ,  are  conscious  of  rudimentary  movements  of 
the  tongue  and  lips  that  accompany  the  production 
of  the  mental  phenomenon. 

In  some  cases,  but  usually  at  a  much  later  period, 
the  patients  hear  voices  in  each  of  the  two  ears  (double 
hallucinations.  Magnan).  On  one  side  he  hears 
disagreeable  things,  insults  and  threats ;  on  the  other, 
agreeable  words,  encouragement  and  advice.  These 
two  kinds  of  hallucinations  constitute  for  the  patients, 
says  Seglas,  the  attack  and  the  defense. 

As  Lasegue  has  justly  remarked,  hallucinations 
of  sight  are  very  rare  in  the  insanity  of  persecution. 
The  patient  hears  his  enemies,  recognizes  more  or 
less  fully  their  voices,  but  generally  does  not  see 
them.     His  false  visual  sensations,  when  he  has  them, 


PEOGEESSIVE  SYSTEMATIZED  INSANITY,  225 

consist  mainly  in  hostile  apparitions,  in  grimacing 
figures,  in  writings  full  of  threats,  in  changes  of  ap- 
appearance  of  persons  and  things,  which  he  accuses 
his  enemies  of  making  him  see  by  their  machinations. 
It  is  exceptional  that  visual  hallucinations  occur  in 
any  connected  fashion,  at  least  when  not  complicated 
with  other  pathological  conditions,  such  as  alcoholism 
or  hysteria. 

On  the  other  hand,  the  sense  of  smell,  that  of  taste, 
and  especially  the  sense  of  tact,  and  what  we  call  the 
general  sensibility,  internal  or  external,  play  a  great 
part  in  the  delusions.  The  patients  smell  odors  of 
manure,  of  sulphur ;  they  have  the  taste  of  arsenic, 
copper,  or  phosphorus  in  their  mouths,  whence  they 
conclude  that  attempts  are  made  to  poison  their  food, 
and  this  drives  them  sometimes  to  sitiophobia  or,  at 
least,  to  only  eat  certain  substances  and  from  certain 
dishes.  Lastly  they  experience  all  kinds  of  extra- 
ordinary sensations.  They  feel  spasms  produced 
throughout  their  bodies,  cramps,  blows,  torsions, 
burns ;  they  have  had  their  stomachs  torn  out,  their 
abdomens  opened ;  gas  is  blown  into  their  bowels ; 
foreign  bodies  are  introduced  into  their  sexual  organs ; 
they  are  outraged,  sodomized,  masturbated,  their 
semen  is  drawn  off,  etc.,  (genital  persecutory  cases). 
All  these  sensations  are  infinitely  variable,  and  the 
expressions  by  which  the  patients  describe  them  are 
as  typical  as  they  are  impossible  to  reproduce. 

At  this  time  the  patient  begins  to  act  as  a  per- 
secutory case.     Nearly  always  his  first  act  is  a  com- 


226  PARTIAL  OE  ESSEXTIAL  INSAIS'ITIES. 

plaint.  He  addresses  himself  orally,  but  by 
preference  in  writing,  to  the  public  authorities  to 
have  the  persecution  of  which  he  is  the  object  dis- 
continued, and  especially  to  the  police,  the  public 
prosecutor,  sometimes  even  to  the  minister  of  justice 
or  to  the  President.  It  is  such  individuals  as  this 
that  weary  all  the  magistrates,  greater  and  lesser, 
with  their  demands,  and  assail  them  with  the  most 
voluminous  briefs.  At  the  same  time  they  fre- 
quently change  their  residence  to  escape  from  their 
tormentors  and  to  remove  themselves  from  their 
operations  {alienes  migroMurs.  Foville).  But  they 
change  places  or  hide  themselves  in  vain,  the  per- 
secutions follow  them  everywhere. 

After  having  made  vain  efforts  to  obtain  justice, 
and  after  having,  so  to  speak,  exhausted  all  juris- 
dictions, the  patients  attempt  to  secure  justice  for 
themselves.  Now  they  enter  upon  a  new  phase, 
that  of  active  conflict,  which  Lasegue  has  defined 
perfectly  by  saying  that  from  being  subjects  of 
persecution,  they  become  persecutors  themselves. 

The  greatest  peril  any  one  can  incur  is  to  be  taken 
by  a  persecutory  lunatic  for  the  head  of  the  conspir- 
acy that  surrounds  him,  for  the  person  against  whom 
he  must  avenge  himself;  a  peril  that  is  the  greater, 
since  the  victim  is  ignorant  of  it,  and  the  patient  in 
full  possession  of  his  mental  resources,  puts  in  the 
service  of  his  enmity  an  astuteness  and  a  cruelty  truly 
Machiavellian.  This  situation  is  not  without  anal- 
ogy with  the  legendary  Corsican  vendetta,  but  it  is 


PROGRESSIVE  SYSTEMATIZED  INSAXITY.  227 

still  worse.  At  the  inoinent  when  he  least  expects 
it,  when  everything  is  peaceable  and  tranquil,  an 
individual  finds  himself  attacked  suddenly  by  a  person 
he  does  not  know,  often  one  he  has  never  seen  and 
to  whom  he  has  done  nothing  whatever.  Sometimes 
even,  the  patient,  without  having  his  persecutor  def- 
initely fixed  in  his  mind,  attacks  whoever  he  first 
meets,  under  the  influence  of  a  hallucination  of  hear- 
ing or  a  morbid  impulse.  It  cannot  be  too  often 
repeated:  that,  equally  with  the  epileptics, 
and  possibly  even  more  than  these,  the  persecutory 
insane  are,  of  all  lunatics,  the  most  dangerous.  The 
greater  part  of  the  crimes  committed  outside  of  the 
asylums  by  the  insane,  and  nearly  all  those  committed 
within  them,  are  to  be  credited  to  this  class.  More- 
over, it  is  not  onh'"  homicides  that  they  commit ; 
they  may  attempt  arson,  poisoning,  and  occasionally, 
contrary  to  general  opinion,  and  in  exceptional  cases, 
suicide.  Whatever  their  acts  may  be,  they  very 
frequently  assume  the  impulsive  character. 

During  all  this  time  the  patient  is  more  and  more 
wrapped  up  in  his  delusions,  which,  having  taken 
definite  shape,  become  S3''stematized,  and,  as  we  may 
say,  crystallized,  and,  except  in  some  very  slight  vari- 
ations, remain  thereafter  unchangeable.  If  he  has 
not  yet  created  any  neologisms  to  express  his  con- 
ceptions, he  does  so  now,  and  inserts  in  his  remark  a 
a  greater  or  lesser  quantity  of  odd  and  unknown 
terms  by  means  of  which  he  expresses  his  delusions, 
or  designates  his  persecutors.     This  pathological  lau- 


228  PARTIAL  OE  ESSENTIAL  INSANITIES. 

guage  is  the  best  evidence  of  the  chronicity  of  the 
delusions,  and,  if  there  had  been  any  hopes  of  recov- 
ery, they  have  to  be  dismissed  when  it  appears. 

The  character  of  the  persecutory  paranoiacs  is 
generally  bad.  They  are  suspicious,  quick  to  take 
offense,  cold  and  harsh  in  their  manner,  short  and 
surly  in  their  speech ;  they  answer  questions  addressed 
to  them  impolitely,  and  often  limit  themselves  to  a 
few  very  characteristic  phrases,  such  as:  "I  have 
nothing  to  say  to  you;  you  know  it  better  than  I," 
which  seem  to  carry  the  idea  that  the  questioner  has 
had  occult  communications  with  them,  and  that  their 
thoughts  have  been  heard. 

Further,  the  majority  of  these  patients  are  reticent 
to  the  highest  degree,  and  if  some  of  them  choose  to 
make  public  their  grievances  by  speech  or  writing, 
the  greater  number  keep  them  to  themselves  and  give 
no  outward  demonstration  of  their  hallucinations  and 
their  delusions.  An  extensive  experience  and  a  cer- 
tain amount  of  tact  are  necessary,  therefore,  to 
enable  one  to  overcome  their  obstinate  mistrustful- 
ness, and  penetrate  the  mystery  of  their  conceptions. 
They  exhibit  to  a  large  extent  the  general  appear- 
ance and  special  physiognomy  that  has  been  described 
as  connected  with  hallucinations  of  hearing  in  the 
second  chapter  of  this  work.  Very  often,  they  may 
be  seen  in  silent  converse,  or  even  replying  to  them- 
selves, smiling  or  frowning  at  their  own  remarks, 
answering  tliem,  or  giving  way  under  their  influence 
to  sudden  acts  of    eccentricity  or    violence.     It   is 


PROGRESSIVE  SYSTEMATIZED  INSANITY.  229 

more  particularly  on  account  of  the  persistence  of 
these  hallucinations,  and  the  passive  obedience  in 
which  they  live  to  them,  that  the  persecutoiy  insane 
are  subject  to  sudden  impulses  and  consequently  are 
essentially  dangerous  patients. 

After  a  longer  or  shorter  period,  of  some  weeks 
or  months,  and  still  oftener  of  several  years,  the 
paranoiac  tends  gradually  to  attain  that  condition 
which  is  the  culmination  of  his  disease,  that  is  the 
transformation  of  his  personality. 

This  is  brought  about  in  two  different  ways:  it 
either  occurs  suddenly  under  the  influence  of  a  hal- 
lucination or  suggestion  that  reveals  to  the  patient 
all  at  once,  his  royal  origin  or  his  character  as  an 
exalted  personage;  or  it  occurs  slowly,  through  the 
logical  evolution  of  his  delusions  that  ends  in  con- 
vincing jiim  that,  since  every  one  is  against  him, 
he  must  necessarily  be  a  person  of  some  consequence. 
In  either  case  the  result  is  the  same,  a  new  person- 
ality comes  on  the  stage  whose  presence  is  announced 
by  ambitious  or  exalted  notions  that  begin  to  appear 
amid  the  delusions  of  persecution  that  had  hereto- 
fore alone  existed.  At  this  moment  the  patient 
enters  upon  the  third  stage  of  his  disorder. 

Mystical  Delirium  (Religious  Insanity). 

Another  delusional  type,  that  may  characterize, 
as  has  been  stated,  the  second  period  of  the  disorder, 
of  partial  insanity,  is  that  of  delusions  of  a  mystical 


230  FARTIAL  OR   ESSEXTIAL  IXSAXITIES. 

or  religious  nature.  Fundamentally  this  condition 
is  the  same  as  that  described,  and  the  same  events 
unfold  themselves ;  the  delusive  explanation  only  is 
chano^ed.  Instead  of  char^^ino:  his  extraordinarv 
sensations  to  human  intervention,  the  patient  attrib- 
utes them  to  divine  agency.  That  is  all  the  differ- 
ence. However  it  maj^  be,  whether  predisposed  by 
their  birth,  their  natural  disposition,  their  education, 
their  ignorance,  or  their  profession,  to  be  influenced 
by  religious  or  superstitious  ideas,  some  patients, 
who  have  experienced,  during  the  earlier  stage  of 
their  disorder,  the  same  svmptoms  as  those  who 
afterwards  suffer  from  persecutory  delusions,  are 
gradually  led  to  attribute  these  phenomena  either  to 
sorcery  or  to  a  divine  or  diabolic  influence.  The 
voices  they  hear  seem  to  them  to  be  those  of  God  or 
of  devils ;  their  bizarre  sensations  are  proofs  to  them 
that  they  are  punished  from  heaven  or  are  persecu- 
ted by  sorcerers.  Almost  invariably,  and  this  is  a 
special  symptom  of  mystic  delusions,  the  patients 
present  internal  illusions  of  a  sexual  nature,  which 
they  interpret  in  various  ways,  but  always  accord- 
ing to  their  delusions.  The  men  think  they  are  sub- 
jected to  carnal  temptations,  sent  from  Deity  to  test 
their  virtue;  the  women  imagine  that  they  have 
secret  relations  either  with  God  or  the  devil,  and  say 
that  they  are  pregnant  by  one  or  the  other.  Hence 
come  the  delusions  of  a  mystic  nature  relating  to  cel- 
estial or  infernal  powers,  which,  in  the  epochs  when 
religious  insanity  raged  as  an  epidemic,  have  given  rise 


tfeOGllESSIVE  SYSTEMATIZED  INSANITY.  231 

to  all  the  subdivisions  and  designations  of  theomania^ 
denionoraania,    demonolatry ^    incubi^  succubi^   etc. 

Whatever  shape  they  may  take,  mystical  delusions 
progress  in  the  same  fashion  as  those  of  persecution. 
They  are  based  on  morbid  sensations,  especially  hal- 
lucinations of  hearing  and  disturbances  of  general 
sensibility,  internal  or  external.  Like  persecutory  de- 
lusional insanity,  this  type  evolves  slowly*  and  tends 
gradually  to  systematize  and  crystallize  itself,  to  reveal 
itself  by  more  and  more  coordinated  conceptions  and 
a  pathological  language  full  of  neologisms  and  odd  ex- 
pressions. Frequently,  indeed,  the  delusions  show  a 
mixture  of  mystical  and  persecutory?"  ideas,  so  that 
the  patient  belongs  at  once  to  both  categories.  Thus 
we  have  some  cases  of  partial  insanity  who  believe 
they  have  divine  revelations  and  have  commerce  with 
Deity  or  with  the  Virgin  Mary,  and  who,  feeling 
themselves  charged  with  upholding  the  true  faith, 
consider  as  their  enemies  and  agents  of  the  devil 
bent  on  their  ruin,  all  sorcerers,  free  masons,  Jesuits, 
priests,  the  members  of  their  own  family,  or  this 
or  that  other  person  whom  they  consider  as  their 
persecutors. 

Mystic  delusions  are  more  often  accompanied  with 
visual  hallucinations  than  are  those  of  persecution, 
and  in  this  they  seem  to  have  rather  close  relations 
with  hysteria. 

Aside  from  these  special  features  the  conditions  are 
the  same,  and  while  not  as  positively  dangerous  as 
the  persecutory  insane,  the  mystics  very  often  com- 


232  PAfi'MAL  OR  ESSENTIAL  INSANITIES. 

mit  barbarous  or  criniinal  acts,  based  on  tbeir  delu- 
sions or  hallucinations.  Sometimes  tliey  go  from 
town  to  town,  catechising,  preaching,  threatening 
the  divine  anger  and  the  vengeance  of  heaven, 
and  even  attempting  violence  against  the  enemies 
and  detractors  of  religion;  sometimes  they  extol 
self  mortification  and.  the  most  shocking  mutilations, 
which  they  practice  upon  themselves  and  urge  their 
followers  to  perform,  thus  founding  more  or  less 
extended  religious  sects  (skoptzi,  etc. ) ;  sometimes, 
obedient  to  the  voices  they  hear,  they  attack  this  or 
that  person  who  seems  to  them  to  take  the  part  of  a 
demon;  and  finally,  they  often  attempt  to  repeat 
the  sacrifice  of  Abraham,  and  immolate  upon  the 
altar  their  own  children. 

In  these  cases,  as  in  the  persecutory  ones, 
the  transformation  of  the  personality  is  grad- 
ually accomplished,  and  in  the  same  manner.  It 
occurs  either  suddenly  as  a  consequence  of  the 
hallucinations,  or  slowly  as,  in  the  progress  of 
the  delusions,  they  come  to  believe  themselves  import- 
ant personages  in  the  religious  world,  charged  with 
a  divine  mission,  destined  to  reform  the  world,  to 
represent  the  Deity;  sometimes  they  imagine  them- 
selves to  be  Christ,  Antichrist,  the  Virgin  Mary,  or 
even  God  himself.  They  then,  like  the  persecutory 
paranoiacs,  enter  into  the  third  period  of  their  disorder. 

Erotic,  Political  Jealous  Insanities. 

It  seems  useless  to  here  enter  into  a  detailed 
description  of  the  erotic,  political  or  jealous  delir- 


PROGRESSIVE  SYSTEMATIZED  INSANITY.  233 

iums.  In  fact,  it  is  rare  for  them  to  appear  singly 
and  as  distinct  forms  of  systematized  insanity. 
Generally  they  are  only  psychological  modalities  of 
the  insanity  of  persecution.  The  patients,  for  exam- 
ple, in  whom  sexual  hallucinations  predominate,  are 
naturally  led  by  that  fact  to  build  up  delusions  of 
persecution  of  a  specially  sexual  or  erotic  nature,  in 
which  they  charge  one  or  many  of  their  enemies  with 
attacks  on  their  chastity,  with  rape,  and  with  all  sorts 
of  outrages,  on  which  they  dilate  with  the  greatest 
satisfaction.  Others  see  political  enemies  every- 
where, they  take  him  for  a  conspirator,  they  watch, 
spy  on  him,  lay  informations  against  him,  try  to  have 
him  arrested  and  imprisoned.  Another  thinks  that 
every  one  is  trj^ing  to  seduce  his  wife ;  he  cannot  see 
any  one  near  her  without  thinking  his  motive  is  to 
betray  or  deceive  her :  he  follows  her,  sees  evil  in  her 
least  actions,  quarrels  with  her,  threatens  her,  and 
often  goes  so  far  as  to  attack  her  in  a  more  or  less 
violent  manner. 

Fundamentally  all  these  are  only  varieties  of  per- 
secutory insanity,  which  are  usually  combined,  either 
singly  or  together,  with  it,  more  or  less  intimately, 
except  only  in  degenerative  cases  in  whom  they  may 
constitute  a  species  apart. 

I  have  had  under  observation  for  five  years,  a 
patient  who  is  very  typical,  inasmuch  as  her  sj'^stem- 
atized  insanity  is  composed  at  tlie  same  time  of  delu- 
sive ideas  and  hallucinations  of  persecution,  erotism, 
politics  and  religion.     From  the  fusion  of  all  these 

Ment.  Mbd.— 15. 


234  PARTIAL  OR  ESSENTIAL  ENTSANITIES. 

elements  there  results  in  her  case  a  protean  persecu- 
tory delirium,  but  one  not  difPering  in  its  characters 
and  evolution  from  the  classic  type.  I  have  been 
very  curious  to  know  how  it  would  terminate  in 
exalted  delusions,  if  it  reached  that  stage,  and  have 
always  thought  that  it  would  take  a  political  color- 
ing, from  the  greater  predominance  of  conceptions 
of  that  nature  over  the  others.  This  is  what  is  being 
at  present  effected,  as  the  patient  who  has  for  years 
been  "insulted  by  the  Hepublic,"  has  during  a 
few  months  begun  to  affiliate  herself  to  the  royal 
family  under  the  characteristic  designation  of 
*' Marie  Antoinette." 

3, — Pekiodof  Transformation  of  the  Personality. 
Ambitious  Insanity. 

As  persecuted,  erotic,  mystic,  political,  or  jealous, 
the  partially  insane  reach,  by  apparently  different 
routes,  the  third  period  of  their  pathological  condi- 
tion, which  consists,  as  we  have  stated,  in  the  trans- 
formation of  their  personality,  revealing  itself  by 
characteristic  ambitions  or  exalted  delusions.  This, 
at  first  only  a  few  ideas  of  pride,  lost  amid  the 
notions  of  persecution,  raj^idly  develops  and  be- 
comes more  concentrated,  and  mingling  with  the 
pre-existing  delusions,  the  patient  at  a  certain  stage 
presents  the  phenomeiion  of  the  manifest  co-existence 
of  persecutory  and  exalted  delusions,  revolving  in 
this  vicious  pathological  circle,  that  he  is  of  conse- 


PEOGRESSIVE  SYSTEMATIZED  INSANITY.  235 

quence  because  he  has  enemies  and  that  he  has  ene- 
mies because  of  his  greatness.  Soon,  however,  the 
exalted  notions  begin  to  predominate  and  to  gradu- 
ally crowd  out  those  of  persecution,  which  undergo 
a  regressive  course  and  become  more  or  Jess  con- 
fused ;  so  that  the  period  soon  arrives  when  the  per- 
secuted individual  becomes  a  megalomaniac^  a  happy 
expression,  that  describes  this  new  condition  very 
aptly,  provided,  however,  that  no  signification  is 
attached  to  the  terms  tnaniac  or  monomania^  since 
this  condition  has  nothing  in  common  with  mania. 

During  all  this  period  the  hallucinations  persist, 
and  it  is  only  after  a  long  time,  and  Avhen  dementia 
begins  to  appear,  that  thej^  become  gradually  weak- 
ened or  diminished. 

The  patients  continue,  for  the  most  part,  to  be 
egoistic,  haughty,  and  vicious.  They  have,  how- 
ever, at  this  time,  a  characteristic  peculiarity,  viz., 
that  they  make  themselves  up,  after  their  own 
fashion,  in  the  costume  of  the  personage  they  believe 
themselves  to  be.  These  are  the  patients  we  see 
in  asylums  rigged  out  in  plumes,  bits  of  cloth  of 
striking  colors,  crosses,  medals,  chaplets,  and  tinsel 
of  every  description;  they  frequently  do  up  their 
hair  and  beard  in  a  special  and  characteristic  man- 
ner. Nothing  is  more  common  than  to  see  those 
whose  head  and  countenance  recall,  for  example, 
the  conventional  representation  of  the  head  and  face 
of  Christ.  All  these  patients  are  haughty,  dignified 
and  majestic  in  their  attitude,  and  they  do  not  lay 


236  PARTIAL  OR  ESSENTIAL  INSAIflTIES. 

aside  for  an  instant  their  serious  or  solemn  air. 
We  might  say  that  they  are  tragedians  in  some 
royal  role  who  continue  to  play  their  part  in  public 
and  in  their  appropriate  costumes. 

This  period  of  ambitious  insanity  lasts  indeliuitely, 
up  to  the  time  when  dementia  appears  and  enfeebles 
the  mind,  and  gradually  plunges  all  the  vain  concep- 
tions of  the  patient  into  a  chaotic  nothingness. 

Course.  JJurat'wn.  Termination. — The  course 
of  systematized  insanity  is  essentially  a  chronic  one, 
Avith  or  without  remissions,  and  it  covers  the  whole 
period  of  the  patient's  life  from  the  moment  of  its 
develo2:»ment. 

Foreign  authors  have,  nevertheless,  described  an 
acute  form  (paranoia  acuta)  to  which  they  seem  to 
attribute  a  considerable  importance  and  frequency. 
With  us  this  form  has  never  been  described.  If  it 
really  exists  as  a  distinct  variety,  we  can  say  that  it 
is  rather  rare. 

The  duration  of  each  period  is  exceedingly  variable, 
according  to  the  case.  In  some  the  hypochondriacal 
stage  is  very  long;  in  others  the  megalomania  occurs 
almost  at  the  beginning  of  the  stage  of  delusive 
explanation,  so  as  to  seem  sometimes  primary.  It 
may  happen  also  that  the  first  stage,  short  and  not 
pronounced,  passes  unperceived,  or  that  the  patient 
makes  the  second,  so  to  speak,  indefinite,  continuing 
to  have  his  mystical  or  persecutory  delusions  till  he 
finally  dies  without  having  undergone  the  terminal 


PROGRESSIVE  SYSTEMATIZED  INSANITY.  237 

transformation  of  his  personality.  At  bottom  these 
are  all  only  apparent  individual  variations  of  the 
normal  evolution,  in  which  we  can  always  discover 
more  or  less  distinctly  the  typical  progress  of  the 
malady. 

The  usual  termination  of  systematized  insanity  is 
in  dementia,  except  in  the  acute  form  which  is  more 
curable.  The  dementia  is,  however,  very  late  in 
appearing,  and  the  patients  may  continue  in  their 
delusions  15,  20,  or  25  years  without  presenting 
any  marked  enfeeblement  of  their  intelligence. 
Moreover,  even  after  dementia  has  supervened,  they 
still  preserve  evident  traces  of  their  delusions  and 
vestiges  of  their  hallucinations,  which  give  a  pecu- 
liar character  to  their  dementia  (ambitious  dementia) . 

Death  usually  occurs  from  some  complication,  or 
some  intercurrent  disorder,  and  rather  frequently 
from  cerebral  haemorrhage. 

Prognosis. — It  is  not  needful  to  state  how  serious 
is  the  prognosis  of  chronic  or  typical  systematized 
insanity.  When  once  fairly  established  it  is  almost 
always  incurable.  It  is  only  during  the  early  stages 
when  the  delusions  have  not  yet  become  stereotyped, 
that  we  see  recovery  or  at  least  a  temporary  ame- 
lioration. 

Pathological  Anatomy. — Pathological  anatomy 
is  ordinarily  silent.  Nevertheless  we  find  after  death 
more  or  less  marked  cerebral  atrophy.     This,  how- 


238  PARTIAL  OR  ESSENTIAL  INSANITIES. 

ever,  is  only  a  terminal  lesion  explainable  by  the  fact 
of  long  duration  of  the  disease,  and  is,  moreover,  not 
peculiar  to  it,  since  it  is  met  with  in  the  majority  of 
cases  of  insanity  of  long  duration. 

Diag?iosis. — The  diagnosis  of  systematized  insan- 
ity, rather  easy  to  be  made  when  the  disorder  has 
attained  its  culmination,  may  present  difficulty  in 
certain  cases.  It  may  happen,  for  example,  that,  on 
account  of  the  reticence  of  the  patients  and  their 
skill  in  concealing  their  delusions,  as  well  as  the  lack 
in  them  of  any  general  pathological  reaction,  they 
are  mistaken  for  persons  of  sound  mind.  This  error 
is  rather  frequently  committed  by  the  public,  who 
have  a  very  different  idea  of  what  is  insanit3^  To 
avoid  it,  it  is  necessary  to  proceed  in  the  examin- 
ation of  these  })atients  with  all  possible  tact  and 
carefulness. 

In  the  beginning  of  ^^artial  insanity,  Avhen  it  still 
is  comprised  only  of  hallucinations  and  vague  hypo- 
chondriacal and  persecutory  delusions,  it  may  be 
mistaken  for  an  attack  of  delusional  melancholia. 
We  have  already  laid  stress  on  differences  between 
partial  and  generalized  insanity,  especially  melan- 
cholia with  delusions  of  persecution,  and  need  not 
review  them  here.  It  should  be  remembered,  how- 
ever, til  at  melancholiacs  are  contrite  and  paranoiacs 
rebellious.  The  ambitious  delirium  of  the  later 
stage  of  partial  insanity  must  also  not  be  confounded 
with  that  which  may  appear  in  maniacal  excitation. 


PEOGEESSIVE  SYSTEMATIZED  INSANITY.  239 

Besides  the  facts  that  the  former  is  accompanied 
with  none  of  the  general  symptoms  that  character- 
ize mania,  that  it  is  systematized  and  coordinated,  we 
also  know,  as  has  been  especially  shown  by  Achille 
Foville,  that  it  is  not  primary  and  that  it  is  habitu- 
ally accompanied  by  hallucinations,  which  are  never 
present  in  the  ambitious  delirium  of  maniacal  excite- 
ment. There  are  still  better  grounds  for  distin- 
guishing the  megalomania  of  sj^stematized  insanity 
from  that  of  general  paralysis.  Besides  the  history 
of  the  case,  the  characters  of  the  evolution  of  the 
delusions,  so  different  in  the  two  cases,  and  the  pres- 
ence or  absence  of  the  physical  signs  of  paralytic 
dementia,  ought  to  be  sufficient  to  relieve  all  doubts. 
There  are  cases  of  incipient  systematized  insanity 
where  the  patients,  under  the  influence  of  their 
troubles,  take  to  drink,  so  that  a  sort  of  more  or 
less  acute  alcoholic  delirium  may  mask,  or  at  least 
modify,  the  delusive  conceptions  that  form  the  basis 
of  the  affection.  Such  patients  are  commonly 
taken  for  simple  alcoholic  cases,  and  surprise  is  felt 
when,  as  the  toxic  delirium  disappears,  there  is 
unmasked  an  insanity  of  persecution  which  there- 
after progresses  through  its  successive  stages.  One 
ought  always,  therefore,  to  be  reserved  in  the  prognosis 
and  suspicious  of  cases  of  alcoholic  insanity  with 
delusions  of  persecution  and  especially  with  predom- 
inating hallucinations  of  hearing. 

Treatmejit. — The    treatment    of    partial   insanity 
can  hardly  be  more  than  palliative.     It  is  limited  to 


240  PARTIAI.  OR  ESSENTIAL  INSANITIES. 

isolation,  which  is  needful  in  almost  all  cases  on 
account  of  the  essentially  dangerous  character  of 
the  malady.  Moral  treatment  is  ineffective,  or 
nearly  so,  in  this  disease.  One  is  limited  to  the 
treatment  of  complications  and  to  watching  with 
especial  care  to  prevent  the  patients,  as  far  as  pos- 
sible, from  committing  the  dangerous  acts  to  which 
they  are  so  often  inclined. 


SECOND  CLASS 

CONSTITUTIONAL   ALIENATIONS. 

(DEaENBRACIES,    DEVIATIONS,    MeNTAL     InFIRMITIES). 


Cbapter  lD1Firir. 

FIRST  GROUP 

DEGENERACIES  OF  EVOLUTION. 

(Vices  of  Organization). 

I — Psychic  Discordances  {Desharmonies).  (Defect  of 
Equilibrium,  Originality,  Eccentricity).  II — 
Neurasthenias.  (Fixed  Ideas,  Impulsions,  Abou- 
LiAs).  Ill — Phrenasthenias.  (Delusional,  Reason- 
ing, Instinctive).  IV — Monstrosities.  (Imbecility, 
Idiocy,  Cretinism). 

The  degeneracies  of  evolution,  or  vices  of  psychic 
organization,  differ  from  the  insanities  in  that  they 
involve  the  intellect  in  its  constitution  itself  and  not 
merely  in  its  mode  of  activity.  They  represent 
anomalies  of  the  organ,  the  insanities  being  the  dis- 
orders of  its  function. 

From  this  fundamental  point  start  all  the  other 
differential  characters  which  may  he  summed  up  as 
follows : 


242  DEGENERACIES  OF  EVOLUTION. 

The  degeneracies  of  evolution  are  not  mere  acci- 
dents of  psychic  life,  but  are  genuine  original  de- 
fects, usually  involving  the  whole  race  (hereditary 
insanity  in  that  of  degeneracy:  Morel,  Legrand  du 
Saulle,  jVIagnan) .  Tliey  show  themselves  also  in  the 
physical  organization,  as  well  as  in  the  mental,  by 
embryogenic  deviations  or  malformations,  that  go 
under  the  name  of  stigmata  or  degeneracies,  (Morel, 
Magnan).  These  malformations  or  stigmata  are 
essentially  indelible,  and  may  be  accompanied  by  va- 
rious, more  or  less  lasting,  neuropathic  or  phreno- 
pathic  disturbances  (episodic  syndromes:  Magnan). 

The  degeneracies  of  evolution  include  four  genera 
or  progressive  degrees:  (1)  Psychic  discordances, 
deshav'inonies  (defects  of  equilibrium,  originality,  ec- 
centricity) ;  (2)  Neurasthenias  (fixed  ideas,  impul- 
sions, aboulias) ;  (3)  phrenasthenias  (delusional, 
reasoning,  instinctive) ;  (4)  monstrosities  (imbecility, 
idiocy,  cretinism).  "VVe  will  examine  successively 
each  of  these  divisions. 

§1.     PSYCHIC  DISCORDANCES.— DISHARMONIES. 
(Defects  of  Equilibrium,  Originality,  Eccentricity). 

The  disharmonies  form,  so  to  speak,  the  transition 
between  the  normal  and  the  pathological  conditions. 
They  arc  the  border  ground  on  which  we  find  indi- 
viduals, intelligent  and  sometimes  even  brilliantly 
endowed,  but  mentally  incomplete  and  already  the 
bearers  of  a  blemish  that  reveals  itself  by  a  defect 


PSYCHIC  DISCOEDAiTCES.  243 

of  harmony  and  poise  between  the  various  faculties 
and  inclinations.  We  can  distinguish  as  types  of 
these:  the  ill-balanced,  the  original,  and  the  eccen- 
tric. 

The  III  Balanced.  [Des^quilibres) . — These  are 
abnormal  individuals  characterized  by  an  unequal 
assemblage  of  deficiencies  and  excess  in  their  psychic 
elements. 

From  their  infancy  they  are  marked  for  their 
precocity,  their  aptitude  to  perceive  and  comprehend, 
and  at  the  same  time  for  their  capriciousness,  their 
wayward  disposition,  their  cruel  instincts,  and  their 
attacks  of  violent  and  almost  convulsive  passion.  At 
the  period  of  pubert}^  they  suffer  from  nervous 
troubles  such  as  chronic  or  hysteriform  disturbances, 
migraines,  neuralgias,  convulsive  tics,  simultaneously 
with  transitory  spells  of  excitement  or  depression, 
with  exaggeration  of  certain  psychic  or  emotional 
tendencies  (mysticism,  onanism,  vague  sexual  as- 
pirations, desire  to  travel,  or  for  conspicuous  actions). 

After  maturity  they  are  complex  beings,  hetero- 
geneous, made  up  of  disproportioned  elements,  contra- 
dictory qualities  and  defects,  and  as  over  endowed 
in  some  directions  as  they  are  deficient  in  others. 
Intellectually,  they  often  possess  in  a  very  high 
degree,  the  faculties  of  imagination,  of  invention, 
and  of  expression,  that  is  to  say,  the  gifts  of  speech, 
the  arts,  and  poetry;  on  the  moral  side,  they  possess 
a  singular  emotivity,  or  rather,  sensibility.  What 
they  lack,  more  or  less  completely,  is  good  judgment, 


244  DEGENERACIES  OF  EVOLUTION. 

the  moral  sense,  and  especially  continuity  or  logical 
eonseeutiveness,  a  nuity  of  direction  in  intellectual 
production  and  the  actions  of  life.  It  follows,  that 
in  spite  of  their  often  superior  quahties,  these  persons 
are  incapable  of  conducting  themselves  in  a  rational 
manner,  of  following  regvdarly  the  exercise  of  a 
profession  that  seems  well  beneath  their  capacity,  of 
looking  after  their  interests  or  those  of  their 
families,  of  carrying  on  business  prosperously,  or  of 
directing  the  education  of  their  children:  their  exis- 
tence therefore,  constantly  recommencing,  is  one 
long  contradiction  between  the  apparent  wealth  of 
means  and  poverty  of  results.  They  are  the  Utopians, 
the  theorists,  the  dreamers,  who  are  enamored  with 
the  best  things  but  accomplish  nothing. 

The  public  which  sees  only  the  brilliant  exterior 
often  looks  upon  these  individuals  as  artists  and 
superior  beings.  The  medal  is  reversed,  however, 
to  those  who  are  compelled  to  associate  with  them 
and  share  their  existence;  they  see  their  defects, 
their  incapacities  and  evil  tendencies,  of  which  they 
are  not  merely  the  witnesses,  but  also  the  victims. 

Aside  from  their  lack  of  mental  poise  these  indi- 
viduals also  display  an  excessive  emotional  sensibility 
and  an  enfeeblement  of  psychic  energy  that  reveals 
itself  by  a  noticeable  predominance  of  spontaneity 
over  reflection  and  volition.  Hence  their  inability, 
their  instability,  and  their  irresolution;  hence  also 
their  alternations  of  apathy  and  activity,  of  excite- 
ment and  torpor,   their  violent  attacks  of   passion 


PSYCHIC  DISCORDANCES.  245 

and   their    cries    of    despair    for    the    most    trivial 
and  slightest  reasons. 

In  certain  cases,  finally,  we  can  already  distinguish 
in  them  the  existence  of  some  of  the  physical  signs 
that  characterize  the  conditions  of  degeneracy. 

Originality — Eccentricity. — The  psychic  dis- 
harmonies exhibit  themselves  in  a  more  marked 
degree,  besides  the  lack  of  balance  above  described, 
in  certain  morbid  peculiarities  that  pass  under  the 
names  of  singularities  or  eccentricities.  These  are 
isolated  anomalies,  manias  as  they  are  properly 
called,  that  are  shown  in  the  external  habits,  in  a 
style  of  dress,  of  wearing  the  hair,  of  walking,  of 
writing,  or  of  speaking  perhaps  in  an  odd  gesticula- 
tion, a  phrase,  or  tic^  or  a  grimace.  Frequently,  also, 
originality  reveals  itself  in  an  imperious  overmaster- 
ing tendency  which  impels  the  individual  in  a  definite 
intellectual  or  emotional  direction  to  the  exclusion 
of  any  practical  or  useful  occupation :  leads  him, 
for  example,  to  surround  himself  with  birds,  flowers, 
or  cats,  to  make  collections  of  insignificant  objects, 
to  become  absorbed  in  ridiculous  investigations, 
calculations,  or  researches.  He  may  have  singular 
emotional  tendencies,  irresistible  attractions  for,  or 
fear  of,  such  and  such  an  animal  or  object.  Excessive 
prodigality,  sordid  avarice,  religious  or  political  ex- 
altation, erotic  excesses,  causeless  falsehood,  a  spirit  of 
intrigue  or  duplicity,  the  passion  for  gambling  or 
drinking,    hypochondria  and  misanthropy,   are  also 


246  DEGENERACIES  OF  EVOLUTION. 

often  observable  in  these  individuals,  who  are  com- 
monly known  to  the  public  under  the  names  of  ec- 
centric persons,  maniacs,  and  cranks. 

It  is  hardly  necessary  to  state  that  all  these  cases, 
being  at  most  only  somewhat  abnormal,  live  at 
liberty  in  society,  and  that  they  are  never  met  with 
in  asylums,  at  least,  except  as  they  may  happen  to 
be  accidentally  taken  with  an  attack  of  insanity. 

§11.     NEURASTHENIAS. 
(Fixed  Ideas,  Impulsions,  Aboulias.) 

The  term  neurasthenia^  invented  by  Beard  in  1868, 
and  accepted  to-day  by  most  writers,  is  a  generic, 
term  applied  to  all  the  morbid  conditions  essentially 
characterized  by  exhaustion  of  the  nervous  system 
(nervous  exhaustion).  It  is  what  has  been  called 
according  to  the  periods  and  the  cases:  nervosisni^ 
irritable  weakness,  spasmodic  conditions,  nervous  as- 
thenia, proteiform  neurosis,  nervous  marasmus,  hys- 
tericism,  spinal  irritation,  hypochondria,  cerebro- 
cardiac  neuropathy,  cerebro-gastric  disease,  etc.,  etc. 
It  is,  therefore,  not  a  disease  but  a  group  of  diseases, 
a  sort  of  diathesis  with  a  most  varied  symptomatic 
expression. 

According  to  the  predominating  phenomena, 
many  forms  are  to  be  distinguished,  the  principal 
ones  of  which  are:  the  cerebral  form  (cerebras- 
thenia) ;  the  spinal  form  (myelasthenia) ;  the  cardiac 


NEURASTHENIAS.  247 

form  (cerebro-cardiac  neuropathy) ;  tlie  gastro-intes- 
tinal  form  (cerebro-gastric  and  intestinal  neuras- 
thenia) ;  and  lastly  the  genital  type  (sexual  neuras- 
thenia) . 

The  essential  cause  of  neurasthenia  is  heredity. 
This,  which  takes  its  source  in  the  different  diathe- 
ses, notably  in  the  neuroses,  the  psychoses,  alcohol- 
ism, arthritism,  syphilis  and  tabes,  induces  from  the 
beginning  in  the  subjects,  a  special  condition  of 
degeneracy  of  the  nervous  system,  upon  which, 
under  favoring  conditions,  the  malady  develops. 
Occasionally,  it  is  true,  hereditary  taint  may  be 
lacking,  and  the  neurasthenia  seems  to  be  due  to  a 
purely  accidental  cause,  like  a  moral  shock  or  the 
traumatism  of  a  railway  spine^  for  example;  but 
even  in  these  cases  it  is  unusual  if  there  did  not 
exist  a  more  or  less  latent  original  predisposition. 

As  occasional  causes  we  have  all  the  circum- 
stances, physiological  or  pathological,  moral  or 
physical,  capable  of  either  suddenly  or  slowly  pro- 
ducing nervous  exhaustion:  puberty,  troublesome 
pregnancies,  local  disorders  of  the  uterus  and  intes- 
tines, typhoid  f^ver,  haemorrhage,  venereal  disorders, 
onanism,  continence,  and  sexual  excess,  mental 
strain,  great  fatigue,  and  excessive  mortifications. 

While  neurasthenia  is  protean  in  its  manifest- 
ations, there  are  still  certain  symptoms  rarely  in 
default,  which,  for  this  reason,  have  been  called  by 
Charcot  neurasthenic  stigmata.  These  are:  a  spe- 
cial form  of  headache  {casque  neurasthenique]  and 


248  DEGENERACIES  OF  EVOLUTION. 

a  sensation  of  emptiness  in  the  head;  insomnia  and 
disturbed  sleep;  psychic  adynamia;  motor  enfeeble- 
ment;  spinal  hyper^esthesia  and  rhachialgia  with 
points  of  election  (^plaque  cervicale.,  plaque  sacree^ 
and  coccygodinia) ;  gastro-intestinal  atony ;  genital 
and  vaso-motor  disorders. 

Cerebral  Neurasthenia  (Obsessions.) 

Cerebral  neurasthenia  the  only  form  with  which 
we  have  to  occupy  ourselves  here,  is  that  form  in 
which  psychic  troubles  predominate.  Based  essen- 
tially upon  an  impotence  of  the  will,  with  preserva- 
tion of  the  intelligence,  properly  so  called,  it  shows 
itself  in  fixed  ideas,  obsessions  (or  besetments), 
active  or  negative  impulses,  all  with  full  conscious- 
ness and  reasoning  powers,  but  irresistible  and 
anxious.  It  comprehends  consequently  a  host  of 
conditions  scattered  here  and  there  in  the  nosology 
under  the  names  of  lucid  insanity,  insanit}'^  with  con- 
sciousness, reasoning  and  .  impulsive  monomania, 
psychic  syndromes  of  the  degenerates,  rudimentary 
paranoia,  etc.,  etc. 

These  different  designations  indicate  serious 
divergences  of  doctrine,  and  psychic  neurasthenia 
is  far  from  being  universally  accejjted  to-day  under 
the  label  and  aspect  we  have  described.  According 
to  some,  it  is  still  a  tonn  of  insanity,  differing  from 
the  other  forms  only  by  its  characters  of  conscious- 
ness and  lucidity  (Ball) ;  according  to  others,  it  is  a 
mental  symptom  of  neurastljenia  (Beard) ;  some  con- 


NEURASTHENIAS.  249 

sider  it  an  elementary  psychic  disorder  analogous  to 
hallucinations,  and  liable  to  be  observed  in  all  neuro- 
ses and  insanities  (Pitres) ;  and  finall}'',  according  to 
some,  it  is  a  sign  of  degeneracy,  not  appertaining 
to  neurasthenia  except  as  a  complication  (Charcot, 
Magnau). 

In  our  view,  emotional  obsession  is   especially  a 

symptom  of  neurasthenia,   having,  it  is  true,   close 

relations  with  degeneracy,  but  only  indirectly  and 

through  the  neurasthenia,  when  that  is  of  a  degen- 

^erative  character,  as  is  usually  the  case. 

It  is,  in  fact,  certain  that  in  the  vast  majority  of 
cases  the  psychic  neurasthenics  are  also  degenerates. 
Their  degeneracy,  which  is,  as  we  have  stated, 
almost  always  the  result  of  heredity,  reveals  itself 
not  only  by  a  defect  of  equilibrium,  but  often  also 
by  more  serious  symptoms,  true  stigmata.  Men- 
tally, they  are  generally  persons  of  intelligence, 
bright  and  quick  witted,  but  timid,  lacking  in 
energy,  weak  willed,  and  endowed  with  a  very  pro- 
nounced emotional  sensibility.  In  early  life,  but 
especially  from  the  age  of  puberty,  they  begin  to 
show  oddities,  tics.,  and  fixed  ideas ;  they  are  readily 
worried  and  worked  up  about  nothing.  Physically, 
they  show  certain  vices  of  conformation,  either  in  the 
genitals,  or  in  the  head,  the  ears,  the  eyes,  the  pala- 
tine vault.  Lastly,  they  are  all  subject  to  various 
nervous  disorders :  neuralgias,  migraine,  palpitations, 
anajmia,    dyspepsia,    exophthalmic   goitre,    cramps, 

convulsions,  etc. 
jtoix.  Us©,— 15, 


250  degent:racies  op  eyoltjtion. 

Such  is  tlie  soil  in  wliich  is  planted  the  emotional 
neurosis  under  the  influence  of  a  favorable  occasional 
cause.  The  rule,  nevertheless,  is  not  absolute,  and 
it  would  be  an  exaggeration  to  say  that  all  these 
patients,  and  all  the  neurasthenics  are  degenerates. 
In  certain  cases  there  exists  at  least  no  apparent  trace 
of  degenerative  heredity,  and  the  neurasthenia  seems 
in  them  to  be  a  true  accidental  disease.  For  this 
reason,  we  believe  that  there  exist  two  very  distinct 
types  of  psychic  neurasthenia :  the  chronic,  constitu- 
tional neurasthenia,  or  that  of  degeneracy,  which  is 
most  frequent,  and  the  acute,  functional,  and  non- 
degenerative  neurasthenia;  both  susceptible  of  being 
accompanied  Avith  obsessions,  but  with  these  of  very 
diJfferent  degrees  of  gravity  in  the  two  cases. 

However  these  psychic  neurasthenias  are  consid- 
ered and  named  (insanity  with  consciousness,  emo- 
tional insanity,  fixed  ideas,  Zioangsvorstellungen^ 
paranoia  rudimentaire^  anxious  obsessions,  morbid 
fears,  episodic  syndromes,  etc.),  the  authorities  are 
none  the  less  in  accord,  in  a  clinical  point  of  view, 
as  to  the  general  characters  that  they  present. 

These  general  characters  have  been  fully  indicated 
by  M.  J.  Falret  in  his  report  on  Obsessions  to  the 
International  Congress  of  Mental  Medicine  of  1889. 

The  following  are  the  conclusions  of  that  report, 
as  voted  on  and  adopted  by  the  Congress : 

"The  different  varieties  of  the  intellectual,  emot- 
ional, and  instinctive  obsessions  have  common 
characters,  which  may  be  stated  as  follows : 


NEITRASTHENIAS.  251 

(1).  They  are  all  accompanied  with  consciousness 
of  the  condition  of  the  disease. 

(2).     They  are  usually  hereditary. 

(3).  They  are  essentially  remittent,  periodical, 
and  intermittent. 

(4) .  They  do  not  remain  isolated  mentally  in  the 
form  of  monomania,  but  propagate  themselves 
throughout  a  very  extensive  range  of  the  intellectual 
and  emotional  nature,  and  are  always  accompanied 
by  distress  and  anxiety,  internal  conflict,  hesitancy 
in  thought  and  action,  and  also  with  physical  symp- 
toms of  an  emotional  kind,  more  or  less  pronounced. 

(5).  They  never  are  accompanied  with  hallu- 
cinations. 

(6).  They  preserve  the  same  psychic  character 
throughout  the  whole  life  of  the  affected  individuals, 
in  spite  of  the  frequent  and  often  prolonged  alterna- 
tions of  paroxysm  and  remission,  and  they  do  not 
change  into  other  forms  of  mental  disease. 

(7).     They  never  terminate  in  dementia. 

(8).  In  some  rare  instances  they  may  be  compli- 
cated with  delusions  of  persecution,  or  with  those 
of  anxious  melancholia  at  an  advanced  stage  of 
the  disease,  while  preserving  fully  their  primitive 
characters." 

Heredity,  as  a  rule,  complete  consciousness,  con- 
comitant anxiety,  absence  of  hallucinations,  remit- 
tent or  paroxystic  character,  indefinite  duration, 
such  therefore,  together  with  a  dwelling  on  their 
condition  which  often  goes  so  far  as  to  lead  them  to 


252  DEGEIs^ERACIES  OF  EYOLUTION. 

desire  death,  are  the  pathognomonic  characters   of 
obsessions  in  a  mental  point  of  vicAV. 

There  should  be  added  here,  also,  the  physical 
neurasthenic  symptoms,  episodic  and  permanent,  of 
which  mention  has  already  been  made,  and  the  prin- 
cipal ones  of  which  are:  headache,  palmar  and 
plantar  hyperidrosis  (cutaneous  dropsy),  flushes  of 
heat  in  the  face,  feelings  of  profound  exhaustion, 
palpitations,  precordial  anxiety,  insomnia,  various 
pains  and  neuralgias,  sensations  of  twitching  of  the 
limbs,  excess  of  oxalates  and  urates  in  the  urine, 
heaviness  in  the  kidneys  and  limbs,  dilatation  of  the 
pupils  and  look  of  hesitation,  localized  muscular 
spasms,  etc. 

If  there  is  general  concord  as  to  the  principal 
symptoms  of  psychic  neurasthenia,  there  is  less  ar- 
gument as  to  their  division. 

Beard  limited  himself  to  enumerating  certain  of 
them  under  the  generic  name  of  morbid  fears,  ac- 
cording to  their  objective  characters. 

Morselli,  who  places  them  in  his  classification  of 
mental  diseases,  under  the  designation  of  rudiment- 
ary paranoia,  divides  them  into  two  species:  (1) 
simple  fixed  ideas,  or  those  with  principle  of  action 
(paranoia  rudimentaria  ideativa),  in  Avhich  the  ob- 
session remains  purely  psychic  without  tendency  to 
the  impulsive  act;  and  (2)  impulsive  ideas  (paranoia 
rudimentaria  impulsiva),  in  which  the  obsession  is 
accompanied  with  an  irresistible  tendency. 

Tamburini,   who   describes   the   same   under  the 


NEURASTHENIAS. 


253 


name  of  fixed  ideas,  recognizes  three  species ;  simple 
fixed  ideas,  emotional  ideas,  and  impulsive  ideas,  ac- 
cordino'  as  the  obsession  causes  a  forced  attention,  a 
distressed  condition,  or  an  action. 

Luys,  who  bases  his  study  on  cerebral  physiology, 
divides  obsessions  into  psychic,  psycho-emotive,  and 
psycho-motor,  according  as  they  involve  singly  the 
centres  of  ideation,  those  of  emotion,  or  the  motor 
centres. 

Falret,  on  clinical  grounds,  also  divides  them,  as 
we  have  seen,  into  intellectual,  emotional  and 
instinctive. 

Lastly,  Magnan,  who,  apropos  to  genital  obsessions, 
has  formulated  an  anatomico-physiological  concep- 
tion of  these  syndromes,  also  divides  these  subjects 
of  obsessions  into  cerebral,  cerebro-spinal,  and  spinal 
cases,  according  as  the  obsession  causes  a  purely 
psychic,  superior  cortical,  or  medullary  reflex,  that 
is  to  say,  a  fixed  idea,  a  conscious  irresistible  im- 
pulse, a  purely  automatic  act. 

As  will  be  readily  seen,  these  divisions  differ  from 
each  other  very  little  in  reality,  and  they  all  end  in 
the  fundamental  distinction  between  purely  psychic 
obsessions  and  obsessions  with  impulsion. 

This  way  of  viewing  the  subject,  although  gener- 
ally adopted,  meets  only  very  imperfectly  the  clinical 
facts.  It  is  impossible,  indeed,  to  establish  sympto- 
matically  so  well  defined  a  distinction  between  a 
fixed  idea  and  an  impulsion.  The  fixed  idea,  in- 
deed, is  only  the  commencement  of  the  impulsion,  if 


254  DEGENERACIES  OF  EVOLTJTION. 

it  is  not  actually  identical  with  it,  a  true  intellectual 
impulsion,  as  it  lias  been  admitted  to  be  by  certain 
authors  (Ball).  As  regards  the  impulsion  itself, 
conscious  and  rational  as  it  is  in  neurasthenia,  it  is  a 
very  complex  syndrome,  in  which  the  unresistible 
act  is  only  the  last  term  of  a  morbid  process,  of 
which  the  fixed  idea  is  the  starting  point  and  the 
anxious  emotion  the  intermediate  stage.  Thus  in- 
sanity of  doubt,  the  type  of  fixed  ideas,  consists  not 
only  in  involuntary  mental  questionings,  but  also  in 
emotional  crises,  often  accompanied  by  automatic 
acts.  So  also  agoraj^hobia  or  fear  of  spaces,  consid- 
ered as  an  emotional  obsession,  is  almost  always 
accompanied  by  a  fixed  idea  of  motor  impotence 
and  a  morbid  act.  So  also  onomatomania,  coprol- 
alia, rupophobia,  homicidal  impulse,  ranked  among 
the  impulsive  obsessions,  include  at  once  the  fixed 
ideas  of  a  word,  of  grossness,  of  contamination,  of 
homicide,  the  anxious  feeling  of  resistance,  and 
finally  the  tendency  to  the  act. 

Further,  the  division  of  obsessions  into  intellect- 
ual, emotional  and  impulsive,  has  the  defect  of  not 
taking  into  account  a  whole  class  of  obsessions,  and 
a  very  important  one:  those  that  are  characterized 
not  by  the  impossibility  of  getting  rid  of  an  idea  or 
act,  but,  on  the  contrary,  that  of  fixing  an  idea  or 
accomplishing  an  act.  It  is  true  that  obsessions  of 
this  kind  pass  under  the  name  of  aboulias,  in  some 
of  the  nomenclatures  (Magnan,  Saury,  Legrain) :  but 
they  figure  there  only  accessorily,  since  they  consti- 


NEURASTHENIAS.  255 

tute  a  special  form  opposed  to  impulsions  of  wMch 
they  are,  so  to  speak,  the  counterpart. 

The  best  way  to  comprehend  obsessions  is  to  go 
back  to  their  source  and  take  pathogeny  as  a 
basis.  But  when  we  analyze  the  intimate  me- 
chanism of  the  phenomenon,  it  is  seen  that  what 
is  affected  in  it  is  the  ?o^7^,  taken  as  a  cerebral  func- 
tion. This  truth  has  been  recognized  by  all  psychol- 
ogists and  clinicists,  from  Billod,  who  first  called 
attention  to  it  in  describing  some  cases  of  this  kind 
under  the  significant  title  of  lesions  of  the  loill,  down 
to  Morel,  Theo.  Ribot,  and  Tamburini,  who  have 
made  it  very  evident. 

What  then  is  the  will  and  how  does  it  normally 
act?  From  various  excitations,  of  the  sensibility, 
stimuli  pass  to  the  nervous  centres,  where  they  finally 
produce,  after  a  series  of  more  or  less  complicated 
operations,  two  kinds  of  reactions:  the  reaction  of 
arrest  or  inhibition  which  suppresses  certain  others; 
and  the  reaction  of  reinforcement  or  impulsion,  which 
transmits  the  others  to  the  motor  organs  to  be 
transformed  mto  acts. 

The  will,  according  to  this  synthetic  formula, 
is  therefore  a  cerebral  function  composed  of  three 
elements :  a  centripetal  element,  the  excitation,  and 
a  double  reactional  element,  the  function  of  arrest 
and  the  motor  functions.  The  normal  condition 
exists  in  the  equilibrium  between  these  three  forces, 
and  there  is  plainlj^  a  lesion  of  the  will  whenever 
this  equilibrium  is  destroyed. 


256  DEGEJsTERACIES  0^  EVOLrTlON. 

Many  examples  present  themselves.  In  the  one 
the  lesion  involves  the  excitant  element,  the  reac- 
tional  forces  remain  the  same,  and  then  either  the 
excitation  may  be  too  strong  and  there  follows  an 
irresistible  act  (imjDulsion) ,  or  it  may  be  too  weak  or 
be  wanting,  and  activity  is  suspended  (aboulia).  In 
another  case  the  excitation  being  normal,  the  lesion 
ma}^  affect  the  reactional  element,  and  if  the  arrest 
is  the  function  involved  an  irresistible  act  (impul- 
sion) is  produced,  or  if  it  is  the  motor  function,  then 
action  is  impossible  (aboulia). 

Lesions  of  the  will  are  therefore  of  two  kinds :  (1) 
those  due  to  disorder  of  the  centripetal  excitation 
(impulsion  and  aboulia,  from  excess  or  deficiency  of 
excitation) ;  (2)  lesions  due  to  disorder  of  central  reac- 
tion (impulsion  or  aboulia  from  deficient  force  of 
arrest  or  motor  force). 

This  classification  of  the  diseases  of  the  will,  psy- 
chological and  theoretical  as  it  may  seem,  is  none 
the  less  a  clinical  one,  and  suffices  to  explain  the 
differences  observed  in  the  different  forms  of 
impulsion  and  aboulia.  It  will  be  seen  by  it  how 
the  lesions  of  the  will  from  disorder  of  the  centripetal 
excitant  element  are  met  with  in  the  forms  of  insan- 
ity characterized  by  exaggeration  or  diminution  of 
the  sensibility  (hallucinatory  insanity,  melancholia), 
while  those  due  to  disturbance  of  the  central  reac- 
tions, are  met  with  in  cases  due  to  nervous  exhaus- 
tion (neurasthenia).  Further,  we  see  how  the 
impulsions  of  systematized  insanity,  induced  by  an 


ITEtrllASTHENIAS.  ^0l 

intense  sensorial  excitation,  such  as  a  hallucination, 
takes  on  its  special  character  of  spontaneity  and  sud- 
denness, thus  differing  from  the  impulsion  of  neuras- 
thenia due  to  lack  of  central  inhibition  with  its  more 
or  less  prolonged  resistance  and  its  accompanying 
distress.  In  the  same  way  we  see  the  difference 
between  the  inert,  passive,  and  indolent  aboulia  of 
the  melancholiac  who  is  not  called  to  act  from  lack 
of  peripheral  excitation  (non  vouloir),  and  the  emo- 
tional, painful,  and  even  agonizing  aboulia  of  the 
neurasthenic  who,  called  to  action  by  normal 
incitations,  exhausts  himself  in  superfluous  efforts? 
having  lost  his  active  power  [non  2^ou})oir). 

We  can  therefore  say  that  neurasthenic  obses- 
sions are  lesions  of  the  will  from  disorder  of  central 
reaction,  and  different  from  similar  lesions  met  with 
in  insanity,  and  that  it  is  possible  to  divide  them  into 
impulsions  and  aboulias,  according  as  the  power  of 
arrest  or  that  of  action  is  more  specially  involved- 

Thus  every  neurasthenic  obsession  characterized  by 
an  idea,  an  emotion,  or  an  irresistible  act,  from  insuffi- 
cient inhibition,  is  an  impulsion :  on  the  other  hand? 
every  neurasthenic  obsession  characterized  by  an 
idea,  emotion,  or  impossible  act,  from  insufficiencj'" 
of  motor  action,  is  an  aboulia,  whatever  may  be 
the  final  result  of  the  mental  conflict  that  takes 
place. 

It  is  possible  now  for  us  to  draw  up  a  very  nearly 
accurate  list  of  the  principal  varieties  of  psychic  neu- 
rasthenia that  are  known  at  the  present  time. 


258  degeneracies  of  evolution. 

1. — Impulsive  Neurasthenias  or  Obsessions. 

The  impulsive  neurasthenias  or  obsessions,  are,  as 
has  been  stated,  those  in  which  the  inhibitory  power 
of  the  will  is  disordered. 

In  order  to  comprehend  their  mechanism,  it  must 
be  remembered  that  in  the  condition  of  normal  cere- 
bral automatism  a  crowd  of  ideas  arise  in  the  mind 
which  are  fixed  or  rejected  at  its  will  by  the  volun- 
tary attention  by  means  of  its  double  power  of 
action  and  arrest.  This  is  the  poli/ideisme  physi- 
ologique  of  Ribot,  In  the  impulsive  neurasthenic 
the  conditions  of  cerebration  are  changed:  the 
lessened  will  power  tries  vainly  to  chase  away  an 
idea  induced  by  the  automatism,  and  from  this 
conflict  between  the  voluntary  energy  and  the  pre- 
ponderant spontaneity  arises  a  crisis  of  anguish  and 
anxiety  which  ends  finally  in  an  irresistible  act  or 
exhaustion. 

Impulsive  neurasthenia  is  therefore  nothing  else 
than  a  sort  of  pathological  monoideisme  consisting 
in  the  invasion  of  the  mind  by  an  automatic  idea 
under  the  influence  of  a  diminution  of  the  volition 
of  arrest.  Its  fundamental  characters  are :  (1)  the 
fixed  idea,  which  is  the  very  essence  of  the  impulsive 
obsession;  (2)  in  the  anxious  or  emotional  crisis 
engendered  by  the  efforts  of  resistance  of  the  will ; 
(3)  in  the  final  result,  varying  according  to  the 
case,  and  which  may  be  as  much  inhibitory  as 
dynamogenic,  that  is  to  say,  it  may  end  in  a  psycho- 
motor paralysis  as  well  as  in  an  irresistible  act. 


NEURASTHENIAS.  259 

It  follows  from  this,  as  we  have  alreadj  seen,  that 
all  impulsive  obsessions  are  primarily  intellectual 
and  that  their  starting  point  is  always  a  fixed 
idea,  the  phenomena  of  feeling  and  action  being 
only  a  continuance  and  result.  It  follows  also  that 
any  idea  capable  of  arising  s^Dontaneously  within  us, 
whether  it  refers  to  abstractions,  words,  figures, 
pers*ons,  or  things,  or  any  object  whatever,  may 
become  fixed  in  the  mind  of  a  neurasthenic  and 
consequently  be  the  origin  of  an  obsession. 

This  last  statement  is  confirmed  by  the  facts  that 
show  that  the  various  species  of  obsessions  extend 
and  multiply  the  more  the  better  they  are  known. 
In  reality  their  number  is  unlimited,  and  we  may 
say  that  there  exist  as  many  varieties  of  obsessions 
as  there  are  thoughts  occurring  in  the  human  mind. 

Is  it  logical  under  these  circumstances  to  give  a 
name  and  special  description  to  each  of  these  varie- 
ties, the  number  of  which  extends  and  will  extend 
without  cessation  with  the  progress  of  observation? 
Personally  I  do  not  so  think,  and  it  is  already  long- 
since  I  began  to  notice  this  regrettable  tendency  of 
modern  clinicists  to  individualize  the  infinitely  little. 

Every  one  agrees,  in  the  main,  in  recognizing 
that  neurasthenic  obsessions  are  not  only  identical, 
in  their  essence  and  their  characters,  whatever  form 
the  fixed  idea  may  take,  but  that  they  also  rarely 
exist  singly  in  the  patients  in  whom  we  almost 
always  find  them  combined  with  other  similar  obses- 
sions.    What  utility  is  there  then,  of  creating  for 


^60  DEGENERACIES  OF  ETOLUTION. 

each  of  them  not  only  a  special  designation,  which 
should  strictly  be  understood  as  merely  for  conven- 
ience in  describing  them,  but  also  a  separate  symp- 
tomatology, which  is  perfectly  useless  and  makes 
it  appear  that  we  wish  to  erect  them,  if  not 
into  diseases,  at  least  into  distinct  varieties  of  a 
disease  ? 

Nevertheless,  this  is  what  has  been  done  hereto- 
fore, at  the  risk  of  uselessly  complicating  the  study 
of  these  syndromes,  already  so  difficult.  Let  us  take, 
for  example,  the  fear  of  objects  or  of  contacts,  which 
is  one  of  the  most  frequent  of  the  impulsive  obses- 
sions. It  ought  to  be  sufficient  in  describing  this 
obsession  to  mention  the  principal  elements  or  subjects 
of  the  morbid  fear.  Instead  of  this  the  tendency  is 
to  separate  each  fear  of  objects  and  we  have  already, 
of  these :  the  fear  of  dirt  or  defilement,  (rupophobia 
or  misophobia) ;  the  fear  of  virus  and  poisons  (iopho- 
bia) ;  fear  of  points  (aichmophobia) ;  fear  of  needles 
(belonephobia) ;  fear  of  glass  or  pieces  of  glass  (crys- 
tallophobia) ;  fear  of  objects  of  metal,  door  knobs, 
pieces  of  money  (metallophobia) ;  fear  of  hair  and 
down  of  fruits  (trichophobia).  Moreover,  the  obses- 
sion that  shows  itself  by  fear  of  places  and  of  the 
elements  includes:  fear  of  wide  spaces  (agorapho- 
bia) ;  fear  of  narrow  spaces  (claustrophobia) ;  fear  of 
high  places  (acrophobia) ;  fear  of  precipices  (cremno- 
phobia) ;  fear  of  thunder  and  lightning  (astraphobia) ; 
fear  of  water  and  of  rivers  (potamophobia) ;  fear  of 
fire  (py rophobia) ,  etc.  etc. 


NEUBASTHENIAS.  261 

It  is  evident  that  under  these  conditions,  there  is 
no  limit  to  the  morbid  subdivisions. 

For  my  own  part,  considering  that  all  impulsive 
obsessions  of  whatever  nature,  have  exactly  the  same 
characters,  and  that  the  description  of  each  of  them 
singly  can  only  produce  confusion,  I  am  forced  to  bring 
together  the  similar  forms  and  group  them  in  a  few 
principal  categories.  I  have  thus  admitted  for  con- 
venience of  study:  (1)  obsessions  characterized  by 
indecisions^  of  which  doubting  insanity  is  the  type ; 
(2)  obsessions  characterized  by  fears,  namely :  fear 
of  objects  (ex :  rupophobia) ;  fear  of  places  or  of  the 
elements  (ex :  agoraphobia) ;  fear  of  living  beings 
(ex :  zoophobia) ;  (3)  obsessions  characterized  by 
propensities  or  irresistible  tendencies  (ex:  onoma- 
tomania, kleptomania,  dipsomania,  homicidal  or 
suicidal  impulse.) 

It  will  be  sufficient  to  describe  here  the  principal 
types  of  each  class,  to  give  as  complete  as  possible 
an  idea  of  all  the  varieties,  at  present  known,  of 
impulsive  obsessions.  Still  I  will  only  lay  stress  on 
the  mental  symptoms  they  may  present,  the  general 
phenomena,  that  is  to  say,  the  stigmata  of  degen- 
eracy and  the  bodily  symptoms  of  neurasthenic 
attacks  are  almost  always  found  in  the  majority  of 
the  cases. 

Obsessions  of  Indecision  :  3falacUe  clu  doute. — 
The  insanity  of  doubt  is  the  type  of  the  obsessions 
characterized  by  indecision.     Described  in  1866  by 


262  degen:ehacies  op  evolution. 

Jules  Falret  and  after  him  by  Legrand  du  Saulle, 
Ritti,  and  various  foreign  writers,  it  is  generally 
known  in  Germany  under  the  name  of  Griibelsucht, 
and  in  France  under  the  incorrect  name  of  '"'•  folie 
du  doute  avec  delire  du  toucher.'''*  It  consists  in 
fixed  ideas  that  besiege  the  patient  under  the  form 
of  interrogations,  hesitations,  and  indecisions  of  all 
sorts,  and  of  which  he  anxiously  seeks  the  solution. 

M.  Ball  has  divided  the  doubters  into  five  classes, 
according  to  the  nature  of  the  predominating  ideas : 
the  metaphysicians,  the  realists,  the  scrupulous,  the 
timorous,  and  the  counters.  These  divisions,  prop- 
erly understood,  will  serve  to  facilitate  the  descrip- 
tion of  the  condition. 

The  metaphysicians  are  those  who  are  especially 
haunted  by  abstract  questions.  Their  psychological 
rumination,  as  Legrand  du  Saulle  calls  it,  is  in  ref- 
erence to  Deity,  the  Virgin  Mary,  heaven,  hell,  the 
soul,  the  future  life,  the  world,  and  all  the  most  ob- 
scure problems  of  nature.  They  are  constantly 
inquiring  as  to  the  why  and  wherefore  of  persons 
and  things,  without  being  able  to  drive  from  their 
minds  the  interrogations  thus  irresistibly  imposed 
ujDon  them  and  which  plunge  them  into  inexpressible 
tortures.  M.  J.  Falret  has  very  ingeniously  and 
accurately  called  this  condition  "the  torment  of  the 
question." 

The  realists  are  those  whose  ideas,  with  the  same 
character  of  irresistibility  and  tenacity,  take  on  a 
more  or  less  trivial  nature.     They  revolve  in  their 


NEURASTHENIAS.  263 

thouglits,  for  example,  over  the  conformation  of 
the  genital  organs,  copulation,  the  difference  of  the 
sexes,  the  color  of  the  eyes,  the  presence  of  the 
beard,  the  lowest  and  coarsest  details  of  objects. 

The  scruxjitlous  are  those  whose  doubts  are  in  re- 
gard to  matters  of  religion.  In  their  spells  of 
anxiety  these  patients  torment  themselves  to  the  ut- 
most with  the  ideas  that,  for  example,  they  have 
laughed  at  mass,  have  omitted  some  sin  in  confess- 
ing, have  offended  God  in  some  thought  or  act. 
I  have  known  a  neurasthenic  degenerate,  who,  pos- 
sessed with  an  apprehension  of  this  kind,  would  only 
leave  the  church  walking  backward,  so  as  not  to 
turn  his  back  to  the  altar,  and  who  before  making 
use  of  the  cabinets  read  over  and  over  the  pieces  of 
paper  he  used  without  being  able  to  assure  himself 
that  he  did  not  involuntarily  profane  any  sacred 
word. 

The  timorous  are  those  who  are  fearful  of  com- 
mitting some  indelicate  action,  and  more  particu- 
larly a  theft.  The  type  of  these  cases  is  the  young 
woman  cited  by  Esquirol  who  was  always  afraid  of 
carrying  off  some  object  of  value,  and,  under  the 
influence  of  this  obsession,  passed  all  her  time  in 
brushing  herself,  taking  off  her  shoes,  examining  her 
hair,  her  hands,  the  floors  and  seats  she  occupied,  for 
fear  lest  something  of  value  should  stick  to  her  per- 
son or  clothing. 

The  counters^  lastly,  are  those  whose  doubts  are 
manifested  under  the  form  of  irresistible  enumera- 


264  DEGEXERACIES  OF  EVOLUTION. 

tions.  This  one  is  compelled  to  count  gas  burners, 
or  the  trees  along  his  route,  and  if  he  believes  he 
has  made  any  mistake,  he  turns  back  once,  twice,  or 
ten  times  over  his  steps  to  make  the  same  calcula- 
tions over  again.  Another  (observation  of  Trelat) 
passes  his  time  in  counting  hoAV  many  times  the 
same  letters  are  repeated  in  the  Scriptures:  how 
many  j^ages  in  this  edition  begin  or  finish  with  a  P, 
or  a  B.,  etc.  Another,  finally,  who  came  to  consult 
Legrand  du  Saulle,  cried  out  in  departing:  "You 
have  forty-four  books  on  your  table,  and  you  wear  a 
waistcoat  with  seven  buttons.  Excuse  me,  it  is  invol- 
untary, but  I  have  to  count." 

Not  all  the  forms  of  morbid  doubt  are  included  in 
this  enumeration  since  they  are  infinitely  variable. 
The  sujDerstitious  and  the  fatalists  who  anxiously 
order  their  lives  according  to  this  or  that  insignifi- 
cant event  might,  for  example,  be  added  to  the  list. 
Persons,  things,  names,  words,  figures  have  for  them 
a  fortunate  or  unfortunate  signification  according  to 
their  nature  or  their  appearance,  and  they  thus  pass 
suddenly  from  terror  to  joy,  and  the  reverse,  accord- 
ing to  the  presage  encountered.  Others  are  im- 
pelled to  perform  some  ridiculous  act,  or  to  repeat 
many  times  the  same  performance  to  exorcise  the 
spell,  and  neglecting  which  they  suffer  increasing  dis- 
tress until  they  finally  yield  to  their  obsession. 
Some  recommence  indefinitely  the  same  work  with- 
out being  able  to  satisfy  themselves  that  it  is  well 
done.     To  dress  th  emselves  becomes  to  them  one  of 


NEXTRASTHEinAS,  265 

the  most  difficult  of  operations,  and  they  pass  whole 
hours  in  j)ntting  on  their  footwear,  buttoning  up 
their  clothing  and  dressing  their  hair,  always  the 
prey  of  an  uncertainty  as  torturing  as  it  is  futile. 
Many  of  them  cannot  put  a  letter  in  the  post-office 
without  hesitating  a  dozen  times  and,  in  S23ite  of  all 
this,  after  it  is  deposited,  asking  if  they  haven't  for- 
gotten the  address  or  dropped  it  outside  the  box; 
they  are  afraid  they  have  left  a  door  unclosed,  a 
light  burning,  a  faucet  running,  and  whatever  they 
do  and  however  much  they  resist  their  fixed  idea, 
they  are  distressed  until  they  become  assured  once 
or  many  times  in  succes^sion  that  their  apprehensions 
are  useless. 

The  obsession  of  doubt,  like  most  of  the  analo- 
gous conditions,  progresses  by  crises,  by  sj)asms, 
more  or  less  acute  and  nearly  connected.  Like 
them  it  is  tenacious,  chronic,  and,  in  general,  incur- 
able. The  patients  demand  an  outside  affirmation 
to  calm  their  ever  reviving  indecision;  but  shortly 
this  moral  support  becomes  insufficient  and  they  fall 
into  a  sort  of  mechanical  automatism;  passing  their 
lives  in  incessantly  repeating  humiliating  or  ridicu- 
lous actions,  muttering  over  the  same  phrases  or 
interjections,  sometimes  even  swearing  at  their  con- 
dition of  which  they  unhappily  retain  full  conscious- 
ness. 

Stress  has  been  laid  in  this  description  only  on  the 
mental   phenomena  of  obsession.     But  it  is  under- 
stood, once  for  all,  as  has  been  said,  that  the  iudica- 
Mest.  Med.— 17. 


266  DEGENERACIES   OP  EVOLTmOif. 

tions  of  degeneracy  are  to  be  met  with  in  most 
cases,  and  that  ahnost  always  the  emotional  attacks 
are  also  habitually  accompanied  by  bodily  symptoms 
(palpitations,  praecordial  pain,  alternating  flushes 
and  pallor,  local  sweats,  especially  of  the  face  and 
hands,  chills,  tremor,  swoons,  etc.,  etc.) 

Obsessions  of  Feae  (Phobias) :  (1)  Fear  of  ob- 
jects.— This  obsession,  mentioned  by  Morel  in  1866, 
in  his  Dellre  emotif,  was  described  the  same  year 
by  J.  Falret  under  the  name  of  ''partial  alienation 
with  predominance  of  fear  of  contact  of  external 
objects. "  In  this  descrij^tion,  which  remains  classic, 
and  to  which  very  little  has  since  been  added,  Falret 
included  at  once  both  the  malady  of  doubt  and  that 
of  contact.  The  writers  succeeding  him  did  the 
game,  and  Legrand  du  Saulle  evidently  considered 
the  fear  of  contact  as  not  only  one  of  the  manifest- 
ations but  as  one  of  the  periods  of  the  former, 
naming  it  therefore  "insanity  of  doubt  with  delu- 
sions as  to  contact."  The  majority  of  alienists  at 
the  present  time  make  the  doubt  and  the  fear  of 
contact  two  distinct  obsessions.  It  is  certainly  true 
that  these  two  syndromes  are  not  inseparably  allied, 
and  that  one  is  not  a  phase  of  evolution  of  the 
other;  but  it  is  not  less  true  that  the  fear  of  con- 
tact, like,  moreover,  the  majority  of  impulsive 
obsessions,  is  at  bottom  only  a  sort  of  morbid 
doubt. 


STEUEASTHENIAS.  ^67 

The  fear  of  objects*  has  for  its  basis  a  fixed  idea, 
and  consequently  an  anxious  dread.  Its  expression 
is  extremely  varied  and  may  involve  all  kinds  of  ob- 
jects. I  have  criticised  carefully  all  the  observa- 
tions of  fear  of  contacts  so  far  published,  and  find 
that  it  is  manifested  most  frequently  by  fear  of 
hydrophobic  virus  or  that  of  cancer,  or  glanders,  of 
contact  with  phosphorus,  or  with  poisons ;  the  fear 
of  defilement  (rupophobia  or  misophobia) ;  by  the 
'fear  of  pins,  of  pointed  objects,  of  bone  (aichmo- 
phobia,  belonephobia) ;  by  the  fear  of  bits  of  glass, 
of  jet  (crystallophobia) ;  by  the  fear  of  metallic  ob- 
jects, of  door  knobs,  and  of  pieces  of  money  (met- 
allophobia) ;  by  the  fear  of  hairs  and  especially  the 
down  of  fruits  (trichophobia) ;  and  lastly,  the  rarer 
fears  of  grease,  of  quicklime,  of  mastic,  etc.,  etc. 

The  other  forms  of  fear  of  objects,  less  frequent, 
and  especially  less  studied,  have  for  their  motive : 
the  sight  of  blood  {liematophoMa  of  Fere),  of  knives, 
of  swords,  of  matches,  of  the  sounds  of  bells,  thunder, 
and  firearms,  of  the  odor  of  flowers  and  perfumes, 
the  taste  of  certain  articles  of  food  or  drink. 

Whatever  form  the  morbid  fear  may  take,  and  it 

*The  fear  of  contacts,  which  has  alone  been  in  view  in 
the  descriptions,  is  itself  only  a  form  of  a  more  general  fear : 
the  fear  of  objects,  the  starting  point  of  which  is  not  only 
contact,  but  also  the  sight,  sound,  odor  and  even  the  taste 
of  certain  objects.  It  is  necessary,  therefore,  in  my  opinion, 
to  unite  the  study  of  these  different  forms  and  to  designate 
them  collectively  under  the  generic  name  of  fear  of  objects. 


268  DEGENERACIES    OF   EYOLTJTION. 

is  often  multiple,  it  manifests  itself  by  agonizing 
spells  accompanied  by  usual  neurasthenic  symptoms. 
What  proves  that  this  fear  is  really  of  psychic  ori- 
gin is  that  it  arises  from  only  a  thought  or  a  memory 
of  the  object. 

The  feeling  that  results  from  this  almost  invaria- 
bly impels  the  patients  to  wash  their  hands  to  such 
an  extent  that  reiterated  and  continual  washing  of 
the  hands  may  be  taken  as  one  of  the  most  constant 
signs  of  this  variety  of  obsession.  It  is  a  curious 
fact  also  that  it  is  not  from  any  horror  of  slovenli- 
ness or  because  they  see  dirt  on  their  hands  that  the 
misophobes  are  gi^^en  to  these  ablutions,  since  thej^ 
endure  such  things  very  well  and  may  go  many  days 
or  even  weeks  without  changing  or  bathing ;  on  the 
other  hand,  as  soon  as  they  touch  the  water  the 
obsession  appears,  distressing  and  irresistible,  and 
the  more  they  wash  the  more  they  are  impelled 
to  continue  it  by  an  impulsive  and,  so  to  speak, 
automatic  need. 

It  will  hardly  be  believed  how  far  the  tyranny 
of  a  fixed  idea  wdll  extend  if  one  has  not  closely 
observed  these  unfortunates.  For  nearly  a  year  I 
have  observed  one  such  daily  and  almost  every  hour 
of  the  day,  and  I  avow  that  I  know^  nothing  more 
extraordinary  or  more  saddening  than  this  mixture 
of  perfect  rationality  and  extravagance,  of  conscious- 
ness and  impulse.  I  will  mention  but  one  detail  out 
of  a  thousand.  When  my  patient  goes  to  the  cabi- 
net to  urinate,  he  remains  there  for  hours,  at  least  if 


lT:EinR  ASTHENIAS.  269 

we  do  not  come  to  take  him  away,  since  this  simple 
act  becomes  for  him,  like  all  others,  one  of  frightful 
difficulty.  In  order  to  avoid  having  to  renew  the  act 
often  he  tries  to  empty  his  bladder  completely,  and  as 
the  last  drops  are  drained,  he  makes  violent  efforts  at 
expulsion  and  shakes  the  organ  to  complete  it,  with 
the  result  only  to  throw  him  more  into  anxiety, 
fatigue  and  perspiration.  Next,  when  he  adjusts  his 
clothing,  is  the  most  prolonged  and  difficult  part  of 
the  operation,  since,  haunted  with  the  idea  that  he 
may  imprison  something  unclean  in  his  shirt,-  espe- 
cially a  ^y  or  a  spider,  he  folds  and  unfolds  it  many 
times,  till  flushed,  panting,  and  possessed,  he  finally 
succeeds  in  securing  the  organ  hermetically  against 
his  body  in  many  skilful  wraps,  always  the  same.  If 
any  one  comes,  at  any  time  whatever,  the  obsession 
ceases  and  the  patient  urinates  and  adjusts  himself 
most  naturally  and  rapidly,  for  we  are  aware  that  the 
subjects  of  these  besetments  obtain  in  the  presence 
of  strangers,  or  at  least  in  that  of  certain  individuals, 
a  moral  support,  that  is,  the  backing  of  a  will  that 
they  lack  when  they  are  alone. 

Like  the  malady  of  doubt  of  which  it  is,  as  we 
have  seen,  only  one  of  the  modalities  in  most  cases, 
and  with  which  even  it  is  often  confounded,  the  fear 
of  objects  is  extremely  persistent ;  and  in  spite  of  the 
longer  or  shorter  lulls  that  may  occur,  it  tends  to 
become  chronic  and  to  gradually  overcome  the 
individual,  who  is  reduced  to  the  state  of  an  autom- 
aton, leaving  always  perfect  mental  lucidity  and 
consciousness. 


270  DEGENERACIES  OF  EVOLUTION. 

(2).  Fear  of  places^  elements^  and  diseases. — 
The  type  of  this  form  of  fear  is  agoraphobia^  long 
known  from  the  memoirs  of  Cordes,  Westphal, 
Legrand  du  Saulle,  Ritti,  etc.  It  consists  in  an  obses- 
sion which  has  for  its  object  the  fear  of  wide  spaces. 
In  a  desert  place,  a  very  wide  street,  on  a  bridge, 
in  a  church  or  a  theatre,  the  patient  is  suddenly 
taken  with  the  idea  that  he  cannot  get  over  the 
space  before  him,  that  he  will  die  or  suffer  ill.  A 
d^'^tr-^-*-;^  -ff--c"::  ;o:'o'vr;  rrconipniilod  oy  pnlpitr:- 
tions,  prneeordial  anguish,  feelings  of  oppression,  shiv- 
ering, flushes  and  pallor ;  the  strength  gives  way,  the 
legs  bend,  cold  sweat  occurs,  and  the  subject  falls 
from  weakness.  But  if  he  has  any  one's  arm,  if  he 
walks  alongside  a  wall,  if  he  walks  in  the  shelter  of 
a  carriage,  if  he  carries  a  sword  or  cane,  this  aid, 
small  as  it  may  be,  suffices  to  vanquish  or  relieve 
the  obsession  and  he  overcomes  the  obstacle  with  the 
greatest  facility. 

Cremnophohia^  or  fear  of  precipices,  and  acro- 
phobia^ or  fear  of  summits,  described  recently  by 
Verga,  w^ho  gives  himself  as  one  of  its  victims,  are 
obsessions  alogether  analogous  to  agoraphobia,  with 
this  difference  that  the  patients  feel  their  distress,  not 
in  large  spaces,  but  when  they  are  before  a  gulf,  or 
on  a  height.  An  American  alienist,  who  confesses 
himself  an  acrophobe  like  Verga,  noticed  among  his 
sensations  at  the  moment  of  the  attack,  a  quick  and 
painful  contraction  of  the  scrotum. 

Potamopjhobia  is  an  agonizing  fear  of  the  same 


lOITTRASTHENIAS.  271 

nature  that  has  for  its  object  rivers,  lakes,  etc.  It 
is  esjDecially  felt  on  large  sheets  of  water. 

Claustrophobia^  pointed  out  by  Meschede,  and 
best  known  from  the  memoir  of  M.  Ball  (1879), 
the  opposite  obsession  to  agoraphobia,  i.  e.,  the  fear 
of  confined  spaces.  The  patients  cannot  remain  in 
narrow  qufirtors  and  at  the  mere  idea  that  they  are 
or  iTij^v  be  \t\  ?.  r*!'^",'^  ■!^.\'"/'?  t^iCT  fr.!!  i'lto  r.  ]ir..roicvSwi 
of  distrviss  that  caii;sL\s  them  to  rash  out,  uo  matter 
what  obstacles  they  may  encounter.  They  feel  on 
these  occasions,  says  M.  Ball,  a  sensation  of  con- 
strictive anxiety,  analogous  to  that  one  would  exper- 
ience in  creeping  along  a  long  and  narrow  branch. 

AstrapJiohia.,  described  and  named  by  Beard,  is 
a  similar  dread,  which  has'  for  its  object  thunder 
storms  and  lightning.  It  presents  in  itself  nothing 
worth  being  described.  Its  principal  symptoms,  apart 
from  the  obsession,  are,  according  to  Beard,  pain 
in  the  head,  nausea,  vomiting,  and,  in  some  cases, 
convulsions. 

We  can  compare  these  fears  which  have  intangi- 
ble things  for  their  objects  with  the  fear  of  diseases, 
known  as  nosophoMa.,  or pathoplioljia.  The  patients 
who  suffer  from  this  are  not  to  be  confounded  with 
ordinary  hypochondriacs  and  certainly  not  with 
insane  hypochondriacs ;  since  in  them  the  hypochon- 
dria presents  itself  with  clearly  cut  neurasthenic 
characters,  that  is  to  say,  under  the  form  of  con- 
scious, distressing,  and  paroxysmal  obsessions.  The 
patient,  while  alone  by  himself  or  on  the  street,  is 


272  DEGEXEEACIES  OF  EVOLUTION. 

all  at  once  seized  -with  a  fixed  idea  as  violent  as  it  is 
sudden:  lie  believes  that  his  heart  is  about  to  be 
arrested,  that  his  brain  is  empty,  that  his  limbs  are 
paralyzed,  that  he  will  fall  and  is  going  to  die. 
Panting,  anxious  and  perspiring,  he  either  drops  on 
the  spot,  or  runs  to  a  physician  begging  him  to  save 
him,  or  more  often,  he  hastens  to  swallow  some 
drug  or  cordial  that  he  always  carries  with  him 
in  view  of  this  event.  The  attack  once  over,  he  is 
again  calm,  matters  are  as  before,  and  he  can  attend 
to  his  business  till  the  return,  within  a  longer  or 
shorter  time,  of  the  next  similar  paroxysm.  This, 
it  will  be  seen,  is  a  special  condition,  clearly  differ- 
ent in  its  characters  from  vesanic  hypochondria  which 
is  essentially  continuous  and  uniform  in  its  manifest- 
ations. The  nosophobic  obsession  may  exist  relative 
to  any  disorder  or  organ.  Sometimes  it  may  even 
be  fixed  on  a  simple  morbid  peculiarity,  like  some 
peculiarity  of  the  nose  or  tongue  (Pitres) :  limited, 
tenacious  hypochondriacal  ideas  are,  nevertheless, 
more  characteristic  of  non-neurasthenic  degenerate 
cases. 

(3).  Fear  of  Living  Beings. — The  type  of  this 
form  of  morbid  obsession  is  anthropophohia.,  named 
and  described  by  Beard,  who  considered  it  one  of 
the  more  frequent  forms.  It  consists  in  an  aversion 
to  society,  a  fear  of  seeing  a  crowd  or  of  mixing  with 
one,  or  of  seeing  people  about  one.  In  very  many 
cases,  says  the  American  author,  this  obsession 
becomes  so  pronounced  that  it  impels  the  sufferers 


NEITRASTHEiaAS.  273 

to  abandon  their  occupations  and  their  business 
because  they  cannot  look  their  fellow  men  in  the 
face  or  negotiate  with  them ;  they  are  afraid  of  the 
human  species.  Beard  considered  as  an  important 
and  constant  symptom  of  these  neurasthenics  the  fact 
that  it  is  impossible  for  them  to  look  any  one  steadily 
in  the  face,  and  affirms  that  they  can  be  recognized 
at  first  sight  merely  by  the  manner  in  which  they 
keep  their  eyes  looking  downward  and  away.  In 
some  cases  the  dread  is  limited  to  only  one  sex, 
especially  the  female  (gynephobia)  or  to  certain  classes 
of  persons,  such,  for  example,  as  drunken  men. 

In  other  subjects  the  obsession  takes  the  opposite 
form:  this  is  monophobia^  or  fear  of  solitude.  The 
monophobes  cannot  travel  or  walk  out  alone,  or  leave 
their  homes  without  being  accompanied.  Beard 
cites  the  case  of  a  patient  of  Dr.  C.  L.  Mitchell 
who,  under  the  influence  of  a  fixed  idea  of  this  kind, 
was  brought  to  paying  a  man  twenty  thousand  dol- 
lars to  be  his  constant  companion. 

The  abnormal  emotivity  towards  living  beings 
may  finally  be  directed  toward  the  lower  animals. 
The  aversion  to  certain  animals,  dogs,  cats, 
frogs,  serpents,  mice,  spiders,  etc.,  and  the  exag- 
gerated liking  for  others  are,  it  is  well  known, 
very  common  in  many  persons,  especially  women, 
and  in  non-neurasthenic  cases;  and  it  may  here 
be  remarked  that  all  morbid  obsessions  are 
nothing  more  than  the  reproduction,  carried  to  a 
pathological  extent,  of  ideas,  sentiments  or  tenden- 


274  DEGEITEEACIES  OF  EYOLUTION. 

cies  that  are  all  met  with,  in  a  more  or  less  rudimen- 
tary condition,  in  normal  individuals.  In  the 
neurasthenics  the  obsession  reveals  itself  here  either 
by  a  dread  of  certain  animals  (zoophobia),  or  by 
the  impossibility  of  seeing  them  suffer  in  any  way 
(zoophilia,  antivivisectionists  of  Magnan) ;  in  these 
two  cases  it  gives  rise  to  anxious  attacks  analogous  to 
those  already  described.  The  contact,  the  sight,  or 
cvi'-A  th?  Tv,  ccvlkxttion  of  ccrUun  unhiials  is  siiiilcieut 
to  provoke  thL'se  attacks. 

Obsessiox-Peope]S"sioxs. — Obsession-propensions 
or  obsessions,  properly  so  called,  are  those  in  which 
the  fixed  idea  has  for  its  effect  not  a  fear,  but  an 
irresistible  tendency.  Of  this  class,  are :  onomato- 
mania, kleptomania,  pyromania,  dipsomania,  and 
homicidal  and  suicidal  impulses. 

Onomatomania. — This  is  the  obsession  of  a  name 
or  word,  described  in  1885  by  Charcot  and  Magnan. 

It  follows  from  tlxir  observations  that  this  obses- 
sion may  manifest  itself:  (1)  by  the  distressing  seek- 
ing for  a  word  or  name ;  (2)  by  the  attribution  of  a 
harmful  or  preservative  influence  to  certain  names  or 
words ;  (3)  by  the  impulse  to  rejDcat  some  name  or 
word  that  obtrudes  itself ;  (4)  by  the  obligation  to 
eject,  as  it  were  after  efforts  of  expectoration,  a  name 
or  word  that  has  become  a  veritable  foreign  body  to 
be  thrown  off. 

These  two  last  forms  only  are  irresistible  tenden- 
cies; the  others  appertain  more  to  psychic  indecision 


NETTEASTHENIAS.  275 

or  malady  of  doubt,  in  reference  to  wliicli  I  have 
already  mentioned  them. 

Arithmomania,  described  by  the  same  authors,  is 
only  onomatomania  with  special  reference  to  numbers 
and  figures.  It  is  well  known  that  the  number  13 
plays  a  capital  rdle  in  this  obsession. 

JBlasphemator^  mania,  noticed  long  since  by 
Verga  is  also  a  form  of  onomatomp.nia  in  which  the 
verbal  impulsion  shows  itself  in  o^t"h=!  rnd  hl^py^^^r^^-^. 

Tin'  ii  i\s!:-il!;lo  U-iitleiu-y  to  i"»'poat  '^.>ars:'  or 
obscene  words  is  likewise  the  c]iaracterifc;tic  of  a 
more  complex,  but  certainly  a  similar  condition 
recently  brought  into  notice  by  Charcot  and  his 
pupils,  under  the  title  of  maladie  des  tics  convidsifs, 
or  Gilles  de  la  Tourette's  disease.  A  detailed  account 
of  this  has  been  given  by  Dr.  Catrou  in  a  recent 
thesis  (Paris,  1890). 

This  disease  comprises  two  kinds  of  symptoms: 
(1)  tics,  sudden  and  violent  movements  of  certain 
parts  of  the  body,  especially  the  arms,  having  the 
characters  of  symmetry  and  coordination  and  of 
reproducing,  as  if  from  electric  shocks,  certain  nat- 
urally associated  movements,  always  identical  in  the 
same  individuals,  (sudden  blowing  of  the  nose, 
quick  and  repeated  closing  of  the  eyelids,  sudden 
and  automatic  scratching,  sniffling,  expectoration, 
blows  on  the  chest  as  if  in  an  act  of  contrition,  etc., 
etc.);  (2)  coprolalia,  a  term  invented  by  Gilles  de 
la  Tourette  to  designate  the,  as  it  were,  explosive, 
and  forced  ejaculation  of  oaths  and  vile  language  ac- 


276  DEGENERACIES  OF  EVOLUTION. 

companying  each  attack  of  tlie  tics.  There  is 
sometimes  added  an  irresistible  tendency  to  imitate 
words  and  gestures  (echolalia,  eckokinesis,  echoma- 
tism).  The  chief  and  pathognomonic  symptom,  ac- 
cording to  Catrou,  is  the  coprolalia. 

The  malady  of  tics  is  chronic,  remittent,  parox- 
ysmal, and  usually  incurable.  It  is  frequently 
connected  with  some  of  the  ah-eady  described 
obsessions. 

We  have  here  undoubtedly  a  degenerative  condi- 
tion of  the  neurasthenic  type,  as  the  tics  are  nothing 
but  the  stigmata  of  an  hereditary  neuropathy, 
analogous  to  the  others.  As  M.  Charcot  well  says 
(Tuesday  lectures) :  ' '  The  tic  is  a  disorder  that  is 
only  in  appearance  material ;  it  is,  on  the  one  side,  a 
psychic  disease,  for  there  are  mental  as  well  as  bodily 

Kleptomania. — This  is  the  conscious  and  irresis- 
tible impulse  to  theft.  Tendency  to  steal  may  be 
encountered,  as  a  symptom,  in  some  mental  affec- 
tions, notably  in  general  paralysis,  imbecility, 
dementia;  but  here  it  exhibits  the  special  characters 
of  a  neurasthenic  impulsion.  That  is,  it  presents 
itself  under  the  form  of  an  obsession,  accompanied 
with  resistance  and  distress,  and  which  causes  the 
ordinary  phenomena  of  paroxysmal  attacks.  The 
articles  stolen  are  often  insignificant;  occasionally 
only  one  object,  always  the  same,  is  stolen,  and  the 
patient  accumulates  most  incredible  collections  of 
these. 


NEUEASTHENIAS.  277 

Pyromania. — Pyromania  is  an  impulsion  to  set 
things  on  fire.  Like  all  the  other  morbid  impulses, 
it  is  not  special  to  neurasthenics,  and  it  is  also  met 
with  notably  in  epileptics,  imbeciles,  and  dements. 
With  them  it  is  a  thoughtless,  unconscious,  morbid 
act,  without  conflict  and  concomitant  anxiety,  and  con- 
sequently show^s  none  of  the  pathognomonic  charac- 
ters of  an  obsession.  It  is  most  common  in  the 
female  sex,  and  the  attacks  occur  especially  in  con- 
nection with  the  various  periods  of  sexual  life, 
particularly  at  puberty  and  during  the  menstrual 
period. 

Dipsomania. — Dipsomania  is  the  irresistible 
tendency  to  drink.  This  tendency  is  frequent  in 
the  commencement  of  psychoses  accompanied  by 
excitement,  especially  in  mania  and  general  paralysis, 
where  it  is  one  of  the  manifestations  of  the  morbid 
craving  for  activity  that  leads  the  patient  into  all 
sorts  of  excesses.  In  subjects  of  degeneracy,  and 
especially  in  the  neurasthenics,  it  constitutes  a  true 
dipsomania. 

Magnan,  who  has  given  an  excellent  description, 
lays  stress  on  the  intermittent  and  paroxysmal  char- 
acter of  the  attacks.  At  the  beginning  the  patient 
suffers  from  bodily  discomfort,  anorexia  and  gastro- 
intestinal .disorders,  simultaneously  with  sadness  and 
depression.  Then  the  desire  for  drink  is  awakened, 
an  irresistible  craving  that  must  be  satisfied  at  any 
price.  Now  nothing  can  check  the  patients,  in  spite 
of  their  lucidity  and  efforts  at  resistance,  they  are 


S7§  DEGENERACIES  OF  ETOLtltlOK. 

forced  to  yield  to  the  impulse.  Many  of  them  fly 
from  their  homes  at  this  period,  to  plunge  outside, 
into  the  most  deplorable  excesses  and  debauchery, 
going  even  so  far  as  to  sell  their  clothing  or  prosti- 
tute themselves  to  procure  the  money  for  drink,  and 
when  they  return  after  some  days  they  fall  into  a 
state  of  sadness,  remorse,  and  shame,  which  marks 
the  end  of  the  attack. 

Very  different  from  the  alcoholic  case,  who  intox- 
icates himself  more  or  less  regularly  with  the  liquor 
of  his  choice,  the  dipsomaniac  is  habitually  very 
sober  in  his  intervals  of  calm.  During  his  attack, 
on  the  other  hand,  all  drinks  are  alike  to  him,  pro- 
vided they  are  strong,  and  he  takes  as  readily  to 
drugs  and  poisons  as  to  alcohol.  We  may,  there- 
fore, consider  some  cases  of  the  passion  for  ether, 
morphine,  cocaine,  etc.,  etc.,  as  clinical  varieties  of 
dipsomania. 

Together  with  the  impulsions  above  described  the 
following  analogous  ones,  though  less  frequent,  should 
be  mentioned:  Oniomania^  or  irresistible  impulse 
to  buy ;  the  impulsion  for  gambling  (cubomania) ; 
the  impulsion  to  travel  (dromomania) .  Many  of  the 
cases  described  of  late  years  under  the  generic  name 
of  ambulatory  automatism  appear  to  belong  to  this 
last  variety. 

Impulsion  to  Suicide  and  Homicide. — We  have 
here  only  to  speak  of  the  attacks  of  conscious, 
irresistible  and  distressing  impulsion,  since  impulses 
to  suicide  or  homicide  are,  more  than  any  other  kind, 
met  with  iu  most  forms  of  insanitj. 


JTETJEASTHENIAS.  27^ 

Impulse  to  suicide  is,  we  are  aware,  especially 
hereditary;  and  it  is  particularly  so  in  the  cases  we 
have  here  in  view,  i.  e.,  the  neurasthenic  degenerates, 
in  whom  we  see  it  transmitted  in  the  same  form  from 
ancestors  to  descendants  (homologous  heredity)  and 
sometimes  manifesting  itself  in  both  at  the  same 
period  of  life  (homochromous  heredity). 

The  impulsion  to  homicide  proceeds  in  an  identi- 
cal manner  by  intermittent  and  paroxysmal  crises 
preceded  by  melancholic  prodromata.  The  patients 
are  beset  with  the  fixed  idea  of  killing  this  or  that 
person,  for  example  a  child  they  adore ;  the  sight  of 
that  child,  of  a  weapon,  a  knife,  arouses  their  obses- 
sion and  plunges  them  into  inexpressible  torment; 
they  realize  that  their  will  is  bending  that  they  are 
yielding  to  the  impulse,  and  filled  with  horror,  they 
lament,  flee  from  home,  ask  aid  and  protection  of 
physicians,  not  hesitating  in  some  cases  to  have  them- 
selves locked  up  in  order  to  escape  from  their 
morbid  penchant. 

Erotomania. — Under  the  generic  name  of  eroto- 
mania are  included  the  obsessions  of  a  sexual  nature 
described  abroad  by  Krafft-Ebing  and  by  Magnan 
in  France.  In  some  subjects  the  fixed  idea,  consist- 
ing in  coarse  or  lascivious  reminiscences,  has  for  its 
effect  either  the  excitation  or  the  suppression  of  the 
sexual  power ;  in  others  it  causes  true  impulsive  acts 
such  as :  indecent  exposures  before  women  and  child- 
ren, sometimes  at  a  certain  hour  in  any  place  what- 
ever, even  in  churches ;  rubbing  of  the  penis,  either 


^80  DEGENERACIES  OF  EVOLUTION. 

hidden  or  oj)enlj,  against  the  pelvis  of  women  in 
crowds ;  thefts  of  feminine  articles  as  amorous  relics, 
such  as  plaits  of  hair,  handkerchiefs,  shoes,  jupons, 
etc.,  etc.  In  some  instances  the  impulse,  more  grave 
in  its  nature,  may  give  rise  to  acts  of  sodomy, 
bestiality,  or  even  bloody  deeds  and  violation  of 
corpses. 

Reversed  sexual  instinct  (contrare  sexual  Empfind- 
ung) ,  characterized  by  an  affinity,  especially  psychic 
in  its  nature,  of  certain  individuals  for  the  persons, 
the  costume,  the  occupations,  and  the  habits  of  the 
other  sex,  is  comparable  in  many  respects  to  the 
preceding  obsessions,  and,  like  them,  is  observed 
especially  among  the  degenerates. 

2. — AbOULIC  NEUEASTHElSnAS  OR  OBSESSIONS. 

The  aboulic  neurasthenias  or  obsessions  are,  as  we 
have  seen,  those  in  which  the  will  is  affected  in  its 
power  of  action. 

Contrary  to  that  which  occurs  in  the  impulsive 
obsessions,  where  the  subject  anxiously  endeavors 
to  get  rid  of  an  idea  which  is  imposed  upon  him, 
here  he  tries  vainly  to  transform  an  idea  into  an  act ; 
his  will  is  unable  to  set  into  action  his  motor  system, 
and  his  efforts  in  this  direction  end  only  in  increasing 
his  trouble  and  distress. 

Aside  from  this  difference,  the  aboulic  obsession 
is,  in  reality,  of  the  same  nature  as  the  impulsive  one ; 
it  is  connected  like  it  to  neurasthenic  degeneracy, 
Tad  reveals  itself  by  conscious,  besetting,  paroxysmal 


NETJRASTHENIAS.  281 

attacks,    accompanied    by    the    same   physical    and 
psychic  symptoms. 

The  impulsive  obsession,  it  has  been  seen,  may 
have  any  idea  whatever  for  its  point  of  departure ; 
so  also  the  aboulic  impulsion  may  betray  itself  by 
the  distressing  impossibility  of  any  act  whatever. 
As  many  varieties  therefore  can  be  made  of  aboulic 
as  of  impulsive  obsessions.  Fortunately,  investiga- 
tions have  not  yet  been  pushed  in  this  direction,  and 
there  does  not  exist  to  my  knowledge,  any  detailed 
description  of  this  kind  of  psychic   neurasthenias. 

One  of  the  most  frequent  forms  consists  in  the 
inability  of  the  patient  to  rise  from  a  sitting  posture 
when  he  is  seated.  The  desire  of  the  act  exists  and 
he  makes  efforts  to  accomplish  it,  but  his  power 
of  impulsion  is  insufficient  and  his  most  strenuous 
attempts  only  end  in  the  characteristic  emotional 
crisis  of  neurasthenia.  In  other  cases,  the  patients 
can  walk,  rise,  and  sit  down,  but  cannot  mount 
without  experiencing  the  same  inhibitory  obses- 
sion as  that  of  the  priest  reported  by  Dr.  Lichtwitz 
and  referred  to  by  Krafft-Ebing,  who  could  not  go 
up  the  altar  step,  in  saying  mass,  especially  if  the 
church  was  full  of  people.  If  supported,  however, 
even  to  a  ver^^  slight  extent,  by  a  choir  boy,  he  over- 
came his  obsession.  I  have  given  to  the  first  of 
these  conditions  the  name  of  ananastasia,  from  a 
privitive,  and  dvdaraoig  the  action  of  rising,  and 
to  the  second  that  of  ananabasia  (d-dvajBdctg,  the 
act  of  mounting).  It  will  be  noticed  that  these 
Mgnt.  Med.— -18, 


282  DEGENEEACIES    OP   EVOLUTION. 

terms,  ananastasia  and  ananabasia  are  almost  iden- 
tical witli  atasia-ahasia^  a  term  chosen  by  M.  Char- 
cot to  designate  a  special  neuropathic  modality,  of 
which  M.  Blocq  gave  an  excellent  description  in 
1888,  and  which  is  characterized  by  the  inability  of 
certain  hysterical  subjects  to  stand  erect  or  walk. 

I  ought  to  state  that  this  is  a  pure  coincidence, 
since  it  was  in  1886,  and  on  the  indication  of  students 
of  aggregation  in  philosophy  present  at  my  course, 
that  I  first  employed  these  neologisms,  on  which, 
moreover,  I  lay  no  stress,  since  their  utility,  as  I  have 
many  times  remarked,  seems  very  questionable.  It 
is  well  to  state,  however,  that  the  conditions  of  motor 
inhibition  to  which  they  refer,  differ  sensibly  from 
those  described  by  M.  Charcot.  Ananastasia  and 
ananabasia  signify,  in  fact,  inabilitj^  to  rise  and 
inability  to  climb,  while  astasia-abasia  signifies 
inability  to  stand  erect  or  walk  [a-Grdaiq^  the  act 
of  standing;  d-Bdatg,  the  act  of  walking).  But 
there  is  still  another  distinction  which  is  of  great 
importance.  The  impossibility  of  standing  erect 
and  of  walking  in  astasia-abasia  is  a  continuous  and 
constant  symptom,  undoubtedly  due  to  a  functional 
impotence,  a  dissociation  of  the  constituent  elements 
of  progression  under  the  influence  of  the  neurosis ;  in 
ananastasia  and  ananabasia,  on  the  other  hand,  the 
inability  to  rise  or  walk  only  exists  in  the  attacks 
when  the  obsession  is  produced;  in  the  interval  the 
patient  can  make  whatever  movements  he  pleases. 
There  is  evidently,  aside  from  the  other  peculiarities 


NEUEASTHENIAB.  283 

that  may  be  invoked,  a  capital  difference,  wbich 
shows  that  ananastasia  and  ananabasia  do  not  belong 
to  the  same  category  of  morbid  facts  as  astasia-aba- 
sia.  •  The  former  are  phenomena  of  aboulic  obsession, 
the  latter  appear  to  be  symptoms  of  dissociated  func- 
tional paralysis. 

However  it  may  be,  it  seemed  to  me  to  be  worth 
while  to  compare  them,  if  only  to  establish  the  dis- 
tinction between  pathological  conditions  that  might 
otherwise  lead  to  confusion. 

Besides  the  impossibility  of  rising  and  climbing,  I 
have  also  noticed,  as  an  aboulic  obsession,  the  inability 
to  dress  one's  self  (anesthia,  from  d-£(70?y3,  habit). 
This  inability,  like  all  the  other  inhibitions  of  the 
same  kind  is  intermittent  and  only  occurs  in  attacks ; 
further,  it  is  not  complete  and  is  generally  limited  to 
one  or  several  articles  of  dress,  for  instance,  the 
stockings,  the  shoes,  the  waistcoat,  the  corsage,  the 
hat.  In  the  intervals  between  the  attacks  the  patients 
dress  themselves  with  ease ;  when  the  obsession  super- 
venes they  are  unable  to  accomplish  it,  and  are  com- 
pelled to  stay  in  till  the  return  of  the  normal  calm 
or  to  go  out  only  partially  dressed. 

Another  rather  common  disability  consists  in  the 
inability  of  the  patients  to  speak,  write,  and,  partic- 
ularly, to  sign  their  names  (anupographia).  An 
instance  of  this  kind  is  to  be  found  in  the  work 
of  Billod  on  the  diseases  of  the  will,  and  another 
very  remarkable  one  in  that  of  Morel  on  the  delire 
eynotif.     This  last  is  the  case  of  an  individual  who 


284  DEGENEEACIES  OF  EVOLUTION. 

was  unable  to  write  to  his  betrothed,  to  sign  his 
name,  or  to  pronounce  in  church  the  sacramental 
"yes,"  so  that  the  chaplain  had  to  be  satisfied 
with  his  assent  by  signs. 

There  are  many  other  emotional  impossibilities, 
such,  for  example,  as  the  impossibility  of  fixing  the 
thought,  already  described  under  the  name  of  apro- 
sexia,  the  impossibility  of  sitting  at  table,  of  open- 
ing doors,  of  entering  or  leaving,  and  many  other 
forms  still,  which  future  observations  cannot  fail  to 
bring  to  light.  I  limit  myself  here  to  the  mention 
of  the  principal  ones,  desiring  chiefly  to  show  that 
neurasthenic  aboulia  is  a  special  obsession,  diifering 
fronii  neurasthenic  impulsion  in  that  it  has  for  its 
starting  point  a  lesion  of  the  will  to  act,  while 
the  other  has  for  the  same  a  lesion  of  the  will  to 
arrest  action. 

Diagyiosis. — I  need  not  dwell  at  length  on  the 
diagnosis  of  obsessions,  which  constitute  syndromes 
of  degeneracy  with  absolutely  pathognomonic  charac- 
ters. I  limit  myself  to  calling  attention  to  the  pos- 
sibility of  confounding  aboulic  obsessions  with 
certain  forms  of  depressive  melancholia.  The  dis- 
tinction is  not  always  easy,  since  both  conditions  are 
characterized  in  various  degrees  by  motor  inactivity 
as  well  as  by  discouragement  and  sadness. 

The  analogy,  nevertheless,  is  only  in  appear- 
ance, as  melancholia  is  a  sj^ecial  disorder,  in 
which  the  symptoms  of  inactivity  are  continuous, 
persistent   and    regular    like  all   the    others,  while 


NEURASTHENIAS . 


285 


neurasthenic  lack  of  force  is  only  a  simple 
intermittent  and  paroxysmal  syndrome.  Fur- 
thermore the  incapacity  of  the  melancholiac  does 
not  weigh  upon  him,  he  does  not  suffer  on 
its  account  and  fight  in  vain  against  it;  the  neu- 
rasthenic, on  the  other  hand,  wishes  and  endeav- 
ors to  act,  whence  his  characteristic  distress.  We 
have  explained  this  difference  already,  by  showing 
that  the  aboulia  of  the  melancholiac  is  by  defect  of 
excitation,  while  that  of  the  neurasthenic  is  from 
default  of  central  impulsion  with  retention  of  centri- 
petal excitation. 

It  should  be  recognized,  moreover,  that  the  abou- 
lia of  the  melancholiac  is  very  often  only  an  accessory 
phenomenon  of  the  disorder,  and  that  it  coexists 
with  other  significant  s^nnptoms,  such  as  painful 
delusions,  hallucinations,  refusal  of  food,  and  sui- 
cidal tendency,  which  leave  no  room  for  doubt, 
since,  with  the  exception  of  the  last  named,  they  are 
never  encountered  in  neurasthenic  obsession. 

Prognosis. — The  prognosis  of  neurasthenic  obses- 
sions is  generally,  as  we  know,  very  grave,  and 
the  majorit}^  of  authors  have  insisted  on  the  tenacity, 
chronicity,  and  incurability  of  these  syndromes,  which 
are  very  liable  to  remissions  but  not  to  recovery. 

It  is  certain,  indeed,  that  whenever  the  obsession 
coincides  with  an  actual  and  serious  degeneracy,  it 
has  a  natural  tendency  to  persist  indefinitely.  On 
the  other  hand,  when  there  is  no  degeneracy  or  when 
it  is  present  to  only  a  slight  extent,  the  obsession  is 


286  DEGENERACIES  OF  EVOLUTION. 

perfectly  capable  of  recovering.  We  may  formulate 
in  this  regard  the  rule  that  the  curability  of  the 
obsession  is  in  inverse  proportion  to  the  degree  of 
degeneracy  and  in  direct  proportion  to  the  degree  of 
acuteness  of  the  neurasthenia.  It  is  especially, 
therefore,  in  the  acute  accidental  neurasthenias,  due 
to  severe  moral  or  physical  causes,  that  we  observe 
the  curable  obsessions.  I  should  state  also  that  the 
aboulic  obsessions  seem  to  me  to  be  less  grave  than 
the  impulsive  ones,  and  that  I  have  met  them  more 
frequently  in  acute  neurasthenias  where  the  degen- 
erative characters  were  little  marked. 

Treatment. — The  treatment  of  obsessions  is  blended 
with  that  of  neurasthenia.  How  complex  and  varied 
that  is,  is  well  known.  Nevertheless,  not  all  the  ther- 
apeutic methods  j^roposed  for  neurasthenia  are 
available  against  obsessions,  and  that  of  Weir  Mitch- 
chell,  in  particular,  can  only  be  of  use  in  cases  of 
acute  neurasthenia  with  aboulia,  which  is  unques- 
tionably among  the  rarer  forms.  Isolation  and  con- 
finement are  hardly  any  more  efficacious,  and  the 
rather  numerous  obsessed  patients  who  have  them- 
selves admitted  in  asylums  in  hope  of  a  cure  derive 
from  them,  as  a  rule,  no  decided  benefit.  The 
means  that  seem  to  me  most  useful,  apart  from  the 
pharmaceutical  preparations  appropriate  to  the  case 
(iron,  phosphates,  quinine,  kola,  strychnia,  bromides, 
hypnotics,  etc.),  are  external  agents,  hydrotherapy 
and  baths  of  all  sorts,  massage,  and  especially  elec- 
tricity, either  cerebral  galvanization  in  large  dose, 


PHRENASTHEiaAS.  287 

as  recommended  by  Beard,  or  franklinization  as  pre- 
ferred by  Yigouroux.  It  is  seldom  that  we  do  not 
obtain  by  the  methodic  and  enlightened  employment 
of  this  latter  agent,  if  not  a  cure,  at  least  a  tem- 
porary, and  sometimes  a  lasting,  alleviation. 

Finally,  chiefly  when  all  other  means  have  failed, 
we  may  have  recourse  to  hypnotism,  which  will  pos- 
•  sibly  give  good  results  in  case  its  application  is  not 
difiicult.  I  am  well  aware  that  many  cases  have 
been  reported  during  the  past  few  years,  of  morbid 
obsession  cured  by  hypnotic  suggestion,  but  I  am 
firm  in  the  belief  that  all  the  patients  are  far  from 
being  readily  hypnotizable  in  spite  of  their  good  will, 
and  that  many  of  them  cannot  be  put  to  sleep,  what- 
ever care  and  persistence  is  used  to  effect  it.  Perhaps 
it  will  be  proper  yet  in  this  point  of  view  to  sepa- 
rate the  cases  of  obsession  into  two  classes :  those  of 
accidental  and  acute  neurasthenia,  hypnotizable  and 
curable;  and  those  of  constitutional  and  degenera- 
tive neurasthenia,  non-hypnotizable  and  condemned 
to  absolute  incurability. 

§  III.     PHRENASTHENIAS. 
(Hereditary  Insanity  or  Insanity  of  the  Degenerates). 

Under  the  name  of  phrenasthenias  we  designate 
the  vices  of  organization  or  degeneracies  which 
are  accompanied  by  insanity.  This  is  w^hat  is  called 
by  some  authors  hereditary  insanity  or  that  of  degen- 
erated individuals. 


288  DEGENERACIES  OF  EVOLXJTIOK. 

Described  by  Morel,  studied  successively  by  J. 
Falret,  Legrand  du  Saulle,  Sander,  Krafft-Ebiiig, 
Buccola,  Morselli,  Tonuini,  Riva  and  numerous 
foreign  savants,  this  morbid  condition  lias  been 
especial!}^  elucidated  during  the  past  few  years  by 
Magnan  and  his  pupils. 

Hereditar}^  insanity  is  far  from  being  universally 
admitted  as  a  special  form  of  insanity,  and  the  inter- 
national congress  of  mental  medicine  of  1889  rejected 
this  appellation  to  substitute  that  less  discussed,  but 
quite  as  debatable,  one  of  moral  insanity.  It  is 
impossible,  indeed,  to  give  the  name  of  hereditary 
insanity  to  any  one  form,  whatever  it  may  be,  since 
all  kinds  of  insanity  maj^  be  hereditary.  It  is  not 
less  the  fact,  however,  that  the  degenerates,  i.  e., 
individuals  suffering  from  vices  of  organization,  do 
not  become  insane  like  other  people  and  that  their  in- 
sanity presents  special  characters  of  its  own.  It  is 
therefore  the  word  rather  than  the  thing  that  is  under 
discussion,  and  the  term  insanity  of  the  degenerates, 
or  better,  phrenasthenia,  seems  to  be  one  suited  to 
conciliate  all  views. 

The  principal  character  of  the  insanity  in  the 
degenerates  is  that  it  depends  upon  a  still  graver 
constitutional  condition,  the  mental  infirmity.  In 
ordinary  lunatics  the  insanity  is  everything;  here  it 
is  only  a  secondary  j^henomenon,  superadded  and 
often  episodic.  There  are  therefore  two  distinct 
elements  to  be  considered  in  phrenasthenia :  tlie  vice 
of  organization  and  the  insanity. 


I'HREI?^  ASTHENIAS.  289 

The  vice  of  organization  or  background  we  are 
acquainted  with.  It  is  the  total  of  the  bodily 
and  mental  stigmata  on  which  we  have  insisted  so 
many  times  already,  and  it  suffices  to  say  that  these 
stigmata,  essentially  characterized  by  congenital  devi- 
ations and  malformations,  are  here  more  pronounced 
than  they  are  in  the  disharmonies  and  neurasthenic 
cases,  the  phrenasthenics  representing  a  more  ad- 
vanced degree  in  the  teratological  scale.  It  is  in  these 
patients  especiall}^  that  we  find  the  bodily  anomalies 
of  the  cranium,  face,  ear,  palate,  and  the  genital 
organs,  and,  mentally,  more  or  less  profound  moral 
and  intellectual  lacunae,  coexisting  with  aptitudes 
and  faculties  normal  or  in  excess. 

The  insanity  or  psychopathic  epiphenomenon  has 
very  complex  characters  and  presents  itself  under 
the  most  varied  and  complex  aspects.  Therefore  it 
is  worthy  of  extended  consideration. 

Sometimes  the  insanity  of  the  degenerates  consists 
in  a  true  intellectual  delirium ;  sometimes  it  reveals 
itself  in  moral  and  affective  aberrations,  without 
delusions,  properly  speaking;  sometimes,  finally,  it 
shows  itself  by  tendencies  purely  instinctive.  There 
are  therefore  three  different  varieties  to  be  examined 
successively :  the  delusional,  reasoning,  and  instinc- 
tive phrenasthenias. 

Delusional  Phrenasthenias. 
{JDelire  des  Degeneres.) 
The  delusional  phrenasthenias  represent,  to  speak 
correctly,  the  true  insanity  of  the  degenerates. 


290  DEGENERACIES  OF  EVOLUTION. 

Degenerate  individuals  may  be  subjects  of  any 
form  whatever  of  tlie  common  vesanias:  mania, 
melancholia,  or  systematized  insanity.  But  each  of 
these  has  its  special  characters,  either  in  the 
symptomatology  or,  more  particularly,  in  its  evolu- 
tion. The  attack  of  generalized  insanity  begins  all 
at  once;  the  delirium  is  more  restricted  and  the 
lucidity  greater;  remissions  and  intermissions  are 
almost  the  rule;  recovery  takes  place  suddenly, 
but  relapses  are  always  threatened.  Furthermore, 
mania  and  melancholia  may  be  intermingled,  suc- 
ceed and  alternate,  so  that  some  authorities  have 
been  led  to  consider  the  periodical  and  circular 
insanities  as  belonging  properly  to  the  insanity  of 
degeneracy.  As  regards  systematized  insanity,  it 
shows  itself  under  a  still  more  abnormal  aspect. 
Here  it  is  no  longer  the  typical  psychosis,  evolving 
regularly  and  methodically  by  successive  and  distinct 
periods.  Here  the  different  phases  are  entangled 
and  confused:  sometimes  the  ideas  of  grandeur  and 
persecution  appear  simultaneously;  sometimes  the 
ambitious  delusions  precede  the  persecutory  ones; 
sometimes,  finally,  it  is  an  attack  of  mania  or  melan- 
cholia that  becomes  the  starting  point  of  the  sys- 
tematized delusions,  in  which  mystical  or  sexual 
conceptions  (persecutes  g&dtaux)  often  predominate. 
On  the  other  hand,  the  disorder  may  improve  or  even 
stop  at  any  moment  whatever  of  its  existence  which 
never,  so  to  speak,  occurs  in  typical  systematized 
insanity.     In  a  word,  as  Saury  says,  "the  course  of 


PHEENASTHENIAS.  291 

hereditary  insanity  allows  no  regularity ;  the  lack  of 
method  replaces  the  plan;  absence  of  preparation 
takes  the  place  of  progressive  march.  The  most  di- 
verse manifestations  may  appear,  combine,  or  altern- 
ate without  any  formal  evolution.  Far  from  indica- 
ting sytematization  and  chronicity  the  ambitious 
delusions  lack  all  character  and  may  disappear 
to-day  or  to-morrow." 

This  is  the  form  of  systematized  insanity,  first 
described  by  Sander  under  the  name  of  original 
systematized  insanity,  on  account  of  its  nature  and 
precocity,  that  foreign  authors,  as  was  stated  in  the 
preceding  chapters,  csiW  jmranoia  prima7^ia. 

The  insanity  of  degeneracy  may,  however,  mani- 
fest itself,  not  merely  in  an  ordinary  form,  but  also 
under  an  aspect  that  is  peculiar  to  itself.  It  is  then 
a  special  type,  variable  in  its  delusional  expression, 
but  with  uniform  and,  so  to  speak,  pathognomonic 
characters.  The  delusions  are  connected,  coherent, 
lifelike,  starting  from  false  or  misinterpreted  data, 
but  eminently  logical  in  their  deductions;  they  are 
never  accompanied  with  hallucinations  aside  from 
hypnagogic  or  oneiric  hallucinations  exceptionally  in 
certain  cases ;  they  develop  by  progressive  extension 
of  the  parent  idea,  but  without  undergoing  trans- 
formation or  losing  their  earlier  physiognomy ;  they 
reveal  themselves  in  more  or  less  chimerical,  but 
persistent  and  tenacious  claims,  very  often  aggressive 
and  dangerous ;  this  form  is  incurable  notwithstand- 
ing frequent  remissions,  and  it  usually  terminates  in 
cerebral  complications. 


292 


DEGENEEACIES  OP  EVOLUTION. 


The  lunatics  of  this  class  have  been  placed  among 
the  reasoning  insane  on  account  of  the  persistence  of 
their  lucidity  and  the  logical  character  of  their  delu- 
sions. The}^  have  also  been  (l?^*^^  persecutors  from 
their  very  characteristic  tendency  to  employ  violent 
methods  to  advance  their  cause.  The  public,  easily 
deceiA^ed  by  aj^pearances,  often  takes  them  for 
victims  embittered  by  injustice,  and  it  is  not  uncom- 
mon for  their  delusive  ideas  to  communicate  them- 
selves to  one  or  several  persons  among  their  friends 
{folie  a  deux). 

In  reality  they  are  hereditary  degenerates,  posses- 
sors of  very  marked  mental  and  bodily  imperfections ; 
egoists,  arrogant,  malicious,  greedy  of  notoriety 
and  popular  attention,  and  their  delusions,  the 
more  dangerous  from  their  probability  and  lack  of 
recognition,  impel  them  to  the  most  striking  adven- 
tures and  the  most  serious  crimes.  We  are  indebted 
especially  to  the  works  of  J.  Falret,  of  his  pupil 
Pottier,  and  of  Krafft-Ebing,  for  our  knowledge  of 
this  class  of  the  insane. 

The  characters  above  indicated  will  suffice  to  give 
a  correct  idea  of  the  persecutors,  but  something 
more  will  be  said  in  regard  to  the  principal  varieties 
of  their  insanity,  according  to  which  they  are  divided 
into:  persecutory,  ambitious,  litigious,  erotic  and 
jealous,  mystical,  and  political  types.  At  bottom, 
however,  we  have  the  same  disease  and  the  same 
class  of  patients  in  all ;  they  differ  only  in  the  color- 
ing of  their  predominating  ideas. 


PHREN  ASTHENIAS.  293 

Persecutory  Cases. — Contrary  to  what  occurs  in 
simple  insanity  of  persecution,  the  delusions  are 
here  immediate,  without  hallucinations,  perfectly 
logical  and  objective.  A  soldier,  a  priest,  or  an 
employe,  with  the  abnormal  conditions  of  heredity 
and  temperament  we  have  described,  becomes  the 
subject  of  a  reprimand  or  some  disciplinary  punish- 
ment on  account  of  his  misbehavior  or  his  profes- 
sional deficiencies ;  instead  of  accepting  the  correction, 
his  pride  revolts,  he  calls  it  injustice  and  poses  as  a 
victim.  He  is  therefore  persecuted,  but,  from  the 
first,  he  becomes  a  persecutor.  He  protests,  makes 
charges  and  appeals  so  loudly  and  energetically  that 
he  is  changed  or  loses  his  position.  He  sees  in  this 
only  a  new  grievance  and  his  pathological  spite 
increases.  Thereafter  he  sets  no  limits  to  his  demands ; 
he  makes  charges  upon  charges,  comj^laint  after  com- 
plaint, to  the  authorities ;  he  draws  up  long  justifica- 
tory memoirs,  writes  to  the  journals,  posts  handbills, 
and  appeals  to  the  public  in  behalf  of  the  legitimacy 
of  his  cause.  Often,  the  administration,  wearied 
with  his  importunities  and  touched  by  his  precarious 
situation,  accords  him  some  compensation  or  indem- 
nity ;  but  this  act  of  favor  only  renders  him  still  more 
haughty  and  exacting,  as  he  considers  it  an  admis- 
sion and  recognition  of  his  rights,  so  much  so  that  at 
last,  exasj^erated  by  his  poor  success,  beset  by  pov- 
erty, and  tormented  by  his  fixed  idea,  he  passes 
from  complaints  to  threats,  and  from  threats  to 
crime.     Sometimes  these  individuals  fire  a  pistol  in 


294  DEGEXEEACIES  OF  EVOLUTION. 

the  Chamber  of  Deputies,  on  the  passage  of  a  minis- 
ter or  the  head  of  the  State,  declaring  that  they 
want  "  to  call  attention  to  themselves  and  secure  jus- 
tice "  (false  regicides  of  Regis) ;  sometimes  they 
murder  some  one,  perhaps  their  supposed  enemy,  per- 
haps even  some  unknown  person,  in  order  to  be 
brought  before  the  courts  where  they  can  finally  ex- 
pose their  wrongs  to  the  public  gaze.  If  confined  in 
an  insane  asylum,  they  protest  energetically  against 
their  arbitrary  sequestration,  which  is  only  an  addi- 
tional injury  to  their  minds,  they  demand  an  inquis- 
ition, endeavor  to  escape,  to  kill  some  one,  or,  on  the 
other  hand,  they  profess  to  have  given  up  their  delu- 
sions and  make  the  most  handsome  promises;  but  as 
soon  as  they  have,  in  one  way  or  another,  regained 
their  freedom,  they  commence  at  once  again  their  de- 
mands and  their  criminal  acts. 

Such,  in  brief,  is  the  history  of  the  reasoning  per- 
secutory cases  or  the  persecuted  persecutors.  Many 
of  them  have  become  widely  known  for  the  noto- 
riety they  have  achieved,  and  the  advocate  Sandon, 
the  persecutor  of  the  minister  of  the  Empire,  Busson- 
Billault,  will  always,  in  the  opinion  of  many,  be 
remembered  as  an  undoubted  victim  of  the  errors  of 
science,  from  having  found  in  some  writers,  blinded 
by  political  zeal,  the  virulent  defenders  of  his  path- 
ological grievances. 

Ambitious  Cases. — The  ambitious  persecutors 
differ  in  no  respect  from  the  persecuted  persecutors, 
except  in  one  point :  that  is  that  their  demands  have 


PHEENASTHENIAS.  295 

for  their  object,  not  the  reparation  for  an  injury, 
but  the  recognition  of  an  invention,  a  fortune,  or  a 
title  for  which  they  are  contesting.  Aside  from  this 
their  delusion  has  the  same  evolution  and  mode  of 
displaying  itself.  Without  speaking  of  the  cases  of 
this  kind  which  have  given  rise,  of  late  years,  to 
curious  lawsuits,  I  will  cite  that  of  the  woman  of 
Bordeaux  who,  after  vainly  demanding,  with  innu- 
merable complaints  and  charges,  but  all  apparently 
logical,  the  property  of  a  well  known  banker,  ended 
one  fine  day  by  forcibly  installing  herself  there  with 
her  son,  whom  she  had  made  to  share  her  delusional 
convictions.  I  have  at  present  under  observation, 
in  the  service  of  M.  Pitres,  at  Bordeaux,  a  reason- 
ing degenerate  who  calls  himself  the  son  of  Jules 
Grevy.  His  dying  mother,  he  says,  revealed  to  him 
the  secret  of  his  birth.  Since  that  time  he  has  not 
ceased  to  besiege  the  ex-president  of  the  Republic 
with  his  letters  and  his  visits,  calling  him  ' '  my  dear 
father"  and  demanding  frequent  subsidies.  Con- 
fined for  two  years  at  St.  Anne,  after  a  demand 
without  doubt  a  little  too  pressing  upon  the  sup- 
posed author  of  his  existence,  he  has  evidently  seen 
in  it  only  one  of  the  machinations  of  the  individuals 
interested  in  causing  him  to  lose  a  part  of  his  inher- 
itance. He  never  fails  on  a  certain  day  of  the  year, 
that  of  St.  Jules,  and  on  various  other  occasions,  to 
write  an  affectionate  letter  to  M.  Grevy,  and  he 
shows  triumphantly,  in  support  of  his  sonship,  the 
mail  receipts  showing  that  his  letters  reach  their  des- 


296  DEGENERACIES  OF  EVOLUTION. 

tination,  for  whicli  he  always  takes  care  to  ask.  I  do 
not  kno^\^  whether  this  individual,  who  is  in  his  way  a 
persecutor,  since  he  annoys  M.  Grevy  with  his  fond- 
ness and  his  filial  demands,  will  end  in  raising  his  re- 
quirements and  energetically  claiming  his  birthrights, 
but  this  is  in  the  order  and  may  be  considered  as  a 
natural  consequence  of  his  delusion. 

Litigious  Cases. — The  litigious  persecutors  have 
been  specially  studied  in  Germany  by  Brosius, 
Snell,  Liebmann,  and  particularly  by  Krafft-Ebing 
who  has  described  their  malady  under  the  name  of 
Querulanten  Wahnsi9in,  or  mania  for  disjyutes  or 
lavjsidts.  Their  delusion  is  only  a  variety  of  reason- 
ing persecutive  insanity  the  characteristic  of  which 
is  to  keep  up  legal  ^proceedings. 

An  observation  of  Legrand  du  Saulle,  unfortu- 
nately too  long  for  reproduction  here,  and  to  which 
I  refer  {Annates  medico-jysychologiques^  1878),  can 
serve  as  an  excellent  description  of  this  form.  I 
will  content  myself  with  giving,  in  brief,  here  an- 
other interesting  case  reported  by  M.  Pottier  in  his 
inaugural  thesis.  It  was  that  of  a  young  Avoman 
who,  having  had  disputes  with  the  municipal  com- 
mission of  St.  Ouen,  in  reference  to  the  work  on  a 
sewer  that  affected  her  dwelling,  began  suit  against 
the  commune.  At  the  same  time  she  wrote  to  all 
the  ministers,  had  her  demands  printed  for  circula- 
tion, and  addressed  them  to  the  authorities,  and 
accused  the  courts,  the  police  and  the  "  coalition  of 
dishonest   persons   leagued   against  her,"     On   the 


PHEENASTHENIAS.  297 

twenty-first  of  January,  1886,  she  entered  the 
Chamber  of  Deputies,  walked  up  to  the  public 
tribune,  wrapped  up  in  a  flag  and  crying  "Justice," 
threw  her  pamphlets  to  the  public,  the  members, 
and  the  president.  On  her  flag,  made  by  herself 
out  of  a  piece  of  calico,  was  represented  a  besieged 
house  with  this  inscription:  "  Drama  of  St.  Ouen, 
7th  July,  1884.  Appeal  to  MM.  the  Deputies.  Inva- 
sion of  Ballerich  and  a  band  of  assassins,  who  have 
overrun  us."  The  ushers  arrested  her  and  led  her  to 
the  questure.  When  examined,  she  said  she  wished 
*' to  make  a  disturbance  in  order  to  call  attention  to 
herself  and  her  affairs,"  and  that  she  had  previously 
informed  M.  Grevy,  the  president  of  the  Republic,  by 
letter,  of  this  manifestation.  She  was  allowed  her 
liberty,  and  a  month  later,  February  23,  was  arrested 
at  her  home  for  having  placarded  her  house  with  ' '  In- 
vasion of  Ballerich,  the  infamous !  Justice !  "  She 
was  then  sent  to  the  Salpetriere.  An  interesting 
feature  of  this  case  is  that  the  husband  of  this 
patient  shared  her  delusions  and  signed  with  her 
the  printed  protests.  This  fact  of  communicated 
litigious  insanity  is,  however,  not  infrequent,  and  is 
shown  even  more  clearly  in  one  of  the  observations 
in  my  thesis  on  the  foUe  d  deux. 

M'otiG  cmcl  Jealous  Cases. — A  typical  case,  pub- 
lished by  M.  Taguet,  will  enable  us  to  appreciate 
the  erotic  persecutors  and  will  show  that  they  are 
similar  to  all  the  other  reasoning  lunatics  of  what- 
ever category. 
M£:iT.  Med.— 19. 


298  DEGENERACIES  OF  EVOLUTION. 

"M.  X.  .  .  entered  one  of  the  great  houses  of 
France  as  a  tutor.  The  kindly  reception  offered 
him  by  the  Princess  de  .  .  .  .  led  him  to  hope  that  he 
might  gain  her  affection.  One  day  when  the  prin- 
cess was  occupied  in  writing  bending  over  her  desk, 
X .  .  .  forgot  himself  so  far  as  to  imprint  a  kiss  upon 
her  neck.  The  offense  was  great,  but  he  could  not 
atone  to  her,  and  her  husband,  being  informed,  did 
not  disquiet  himself  further  about  it. 

M.  de .  .  .  died,  and  the  heart  of  the  princess  was 
free.  From  that  moment  X .  .  .  kept  writing  to  her 
strange,  foolish  letters,  protesting  the  purity  of  his 
intentions  and  recurring  constantly  to  the  old  his- 
tory of  the  kiss. 

Finally  he  consented  to  leave  Paris,  but  returned 
almost  immediately.  The  princess  having  shut  her 
doors  to  him,  he  installed  himself  in  a  house  that 
pei-mitted  him  to  spy  her  slightest  movements ;  dur- 
ing the  day  he  followed  her  in  the  churches,  in  the 
magazines,  and  in  the  streets.  One  evening  he 
forced  his  Avay  into  her  carriage  and  covered  with 
burning  kisses  the  hand  of  a  fe'tnme  de  chambre 
whom  he  mistook  for  her.  At  night  he  threw  sand 
and  little  pebbles  against  the  windows  of  her  apart- 
ment. 

On  the  complaint  of  M.  le  due  de .  .  . ,  brother-in- 
law  of  the  princess,  X.  .  .  was  ordered  confined, 
after  an  examination  by  Professor  Lasegue.  At  the 
asylum  his  delusions  continued  and  he  tried  to  prove 
that   he   was   loved   by  the   princess.     Plow   could 


PHRENASTHENIAS.  299 

otherwise  be  explained  that  invincible  attraction 
that  they  felt  for  each  other,  those  projections  for- 
ward of  the  pelvis  and  those  nervous  spasms  that 
Madame  de.  .  .  experienced  in  his  presence,  those 
pressures  of  the  foot,  that  liuid  that  ran  through 
their  fingers  when  they  met? 

When  restored  to  liberty  his  first  care  was  to  sue 
MM.  le  due  de.  .  .  and  doctors  Las^gue  and  Girard. 
de  Cailleux  for  illegal  sequestration,  claiming  one 
hundred  thousand  francs  damages.  He  lost  his 
case. 

After  the  war  in  which  he  served  as  captain  of 
taohiles^  X.  .  .  appealed  from  the  judgment  that 
had  condemned  him  and  demanded  to  be  allowed  to 
plead  his  own  cause.  He  lost  in  the  appeal  but 
sued  for  a  writ  of  error. 

X ...  is,  as  is  seen,  not  only  an  erotomaniac,  but 
also  a  case  of  persecutive  and  litigious  insanity, 
proving  thus  that  the  various  forms  we  have 
described  are  not  distinct  forms,  but  simple  varieties 
of  phrenasthenia,  capable  of  coexisting  in  the  same 
subject 

The  jealous  persecutors  are  analogous  in  all 
points.  The  following  is  a  personal  observation, 
also  interesting  in  this  point  of  view. 

Some  years  since  I  had  occasion  to  examine  a 
young  lady  whose  delusions  were  as  follow^s : 

This  lady,  a  hereditary  and  degenerative  case,  al- 
though very  intelligent,  became  jealous  of  her 
husband  whom    she    blamed   for   not   fulfilling   his 


300  DEGENERACIES  OF  EVOLUTION. 

conjugal  duties  and  for  spending  his  evenings  away 
from  home  with  his  friends.  Having  been  present 
at  a  trial  for  separation  in  which  unnatural  relations 
between  a  husband  and  his  servant  had  been 
charged,  she  was  much  impressed  by  the  revelations 
of  these  abnormal  acts,  of  which  she  had  not  been 
aware  of  even  the  existence,  and  this  was  to  her 
a  beam  of  light.  From  that  moment  she  imagined 
that  if  her  husband  neglected  her,  it  was  because 
he  had  shameful  relations  with  one  of  his  friends, 
M.  X .  .  . ,  and  every  evening,  sometimes  to  a  very 
late  hour,  she  followed  him  in  the  streets  and  spied 
on  him  through  the  windows  of  the  cafe  where  he 
went  to  play  his  game.  Her  daughter,  a  young 
woman  of  eighteen,  very  virtuous  and  lady-like,  was 
informed  by  her  of  her  suspicions  and  shared  them 
fully,  accompanying  or  replacing  her  in  her  noc- 
turnal watches.  Madame  X  ^  ,  . ,  wrapped  up  in  her 
fixed  idea,  sought  and  found  decisive  proofs  in 
everything.  Her  husband  came  home  late,  fa- 
tigued and  with  dark  rings  around  his  eyes,  that 
was  because  he  had  been  indulging  in  his  infamous 
vice:  he  talked  in  his  dreams,  he  was  then  calling 
his  cicisbeo.  The  poor  woman  went  so  far  as  to 
scrutinize  his  soiled  linen,  and  found  in  his  shirts 
and  handkerchiefs  traces  of  his  illicit  pollutions. 
She  showed  us  at  our  examination  a  shirt  of  M. 
X .  .  . ,  spotted  in  the  back  in  several  places  from 
pimples  that  had  suppurated,  and  which  she  had 
preserved  carefully  for   a   month   as   an   evidence, 


PHEENASTHEISnAS.  301 

deducing  even  that  her  husband  in  his  unnatural 
practices  with  his  accomplice,  had  been  the  agent  a 
posteriori^  i.  e. ,  had  played  the  passive  part. 

Full  of  this  idea,  and  while  her  daughter,  excited 
by  her,  inserted  into  her  ' '  cahier  hleu  "  maledictions 
against  the  infamy  of  her  father,  she  became  fully 
a  persecutor,  and  had  encounters  with  the  friend  of 
her  husband,  insulting  and  threatening  him  in  public, 
to  the  extent  of  creating  a  disturbance. 

The  mother  and  daughter  happily  decided  to  leave 
for  Paris,  where  they  are  living,  without  my 
being  able  to  learn  exactly  to  what  their  delusions 
have  come. 

Mystics. — Of  all  the  persecuting  insane  the  mystics 
are  the  ones  that  present  the  most  special  physiog- 
nomy. Mystics  by  temperament,  often  also  by 
heredity,  they  have  an  instinctive  tendency  to  relig- 
ious enthusiasm,  and  by  a  more  or  less  gradual 
process,  they  come  to  conceive  a  religious  system 
which  they  seek  to  spread  and  make  prevail  by  all 
possible  means.  Their  profound  conviction,  their 
enthusiastic  appeals,  and  their  exalted  writings, 
bring  about  sometimes  surprising  results,  and  it  is 
not  uncommon  for  them  to  draw  after  them  a  crowd 
of  proselytes  devoted  to  their  cause  even  to  the  sac- 
rifice of  their  lives.  But  the  point  that  especially 
distinguishes  them,  as  compared  with  other  reason- 
ing insane,  is  the  frequent  occurrence  of  liallucina- 
tions.  These  have  in  them  characters  that  are 
altogether  peculiar.     They  consist  in  supernatural 


302  DEGENERACIES  OF  EVOLUTION. 

revelations  in  the  form  of  apparitions  of  the  Deity, 
the  Yii'gin,  or  the  saints.  These  apparitions  occur 
by  preference  in  the  night  time,  at  intervals,  and  are 
confused  with  the  sleep  to  an  extent  that  it  is  not 
easy  to  distinguish  whether  they  are  genuine  hallu- 
cinations or  23urely  oneiric  phenomena,  i.  e.,  apper- 
taining to  dreams. 

Whatever  they  may  really  be,  these  apparitions 
have  the  effect  of  causing  the  delusive  convictions 
of  the  patients,  and  confirming  them  in  their  pre- 
dominating idea  that  they  have  a  divine  mission  to 
fulfil.  God,  the  Virgin  or  the  saints,  appear  before 
them  in  resplendent  forms,  sometimes  with  sounds 
of  celestial  music,  and  after  having  indicated  to 
them,  in  a  few  seemingly  sybilline  words,  what  they 
are  to  do  for  humanity  and  the  means  they  are  to 
employ,  disappear,  leaving  behind  them  as  it  were  a 
trail  of  light  and  harmony.  Sustained  by  these 
fantastic  visions  which  give  them  the  most  exalted 
ideas  of  their  mission  and  which  often  attract  to 
them  the  reverence  of  the  masses,  they  boldly  come 
to  the  front,  braving  punishment  and  death,  draw- 
ing peoples  and  armies  after  them,  and  it  is  in  this 
way  that  the  founders  of  religions  have  been  able 
to  accomplish  such  surprising  results  and  stir  so 
profoundly  the  faiths  of  humanity.  Without  men- 
tioning those  of  this  class  whose  insanity  is  incon- 
testable, I  will  refer,  as  examples,  to  the  Swede, 
Emmanuel  Swedenborg,  and  Louis  Riel,  the  Can- 
adian   agitator,    hung   at   Regina,    Noveniber    16, 


PHRENASTHENIAS.  303 

1885,  after  having  been  twice  confined  as  an  insane 
person. 

The  political  phreuastheniacs  are  the  same  as  the 
'mystics,  but  with  their  predominant  ideas  directed 
to  matters  of  government  or  state  policy.  It  is  not 
infrequent,  moreover,  for  their  delusions  to  be  at  the 
same  time  composed  of  both  political  and  religious 
ideas.  They  may  .show  their  tendencies  in  various 
ways,  but  they  are  best  represented  by  the  regicides^ 
a  name  given  here  to  those  fanatics,  who,  apart  from 
any  sect  or  conspiracy,  have  assassinated  or  attempted 
to  assassinate  a  monarch  or  ruler  of  their  day.  In 
the  recent  work  I  published  on  celebrated  regicides 
of  past  and  present  times,  I  have  demonstrated  that, 
identical  in  all  countries  and  periods,  notwithstand- 
ing some  apparent  dissimilitudes,  they  are  hereditary 
degenerates,  with  a  mystical  temperament,  who, 
misled  by  a  political  or  religious  delirium,  sometimes 
complicated  with  oneiric  hallucinations,  believe  thena- 
selves  called  to  fill  the  double  role  of  agents  of  justice 
and  martyrs,  and,  under  the  domain  of  an  obsession 
they  are  not  free  to  resist,  they  attempt  to  destroy 
some  great  personage  in  the  name  of  God  and  their 
country. 

The  essential  ruling  idea  of  the  regicides'  insan- 
ity is  that  of  their  glorious  mission,  and,  as  I  have 
pointed  out  in  regard  to  the  simple  mystics,  their 
hallucinations,  when  they  have  them,  consist  in  inter- 
mittent nocturnal  apparitions,  intimately  associated 
with  dreaming  and  sleep. 


304  DEGEXEEACIES  OF  EVOLUTION. 

Folie  d  deux. — I  have  stated  and  have  shown  in 
some  of  the  cases  cited,  that  the  reasoning  insanity  of 
the  degenerates,  whatever  its  form,  persecuted,  am- 
bitious, litigious,  erotic  or  mystic,  is  often  communi- 
cated by  the  patient  to  one  or  more  individuals  of 
his  immediate  surroundings.     It  is  indeed  in  these 
conditions    that  the  folie  d  deux  or  communicated 
insanity,   described  incidentally  by  Baillarger   and 
extensively  and  thoroughly  by  Lasegue,  Falret  and 
Legrand  du   Saulle,  is  developed.     At  other  times 
folie  d  deux  consists,  not  in  the  communication  of  a 
delusion    from    one    person   to    another,  but  in  its 
simultaneous  appearance,  and  by  reciprocal  influence, 
in  two   predisposed   individuals   who  are  together. 
This  is  what  I  have  called  simidtaneous  folie  d  deux. 
I  must  mention  also  the  imjjosed  insanity  of  Maran- 
don  de  Monty  el,  which  is  only  a  variety  of  commu- 
nicated insanity,  and  t\iQ  folie  gemellaire  of  Professor 
Ball  and  certain  English   authors,  characterized  by 
the  simultaneous  aj^pearance  of  a  similar  insanity  in 
two  twins,    even    at   a   distance   from   each  other. 
Lastly  some   foreign  authors  have  described,  under 
the  name  of  induced  insanity,  the  addition  of  new 
delusions  to  the  original  insanity  of  a  patient,  under 
the  influence  of  his  association  with  other  patients. 

Reasoxing  Phrenasthenias. 
{Moral  Insanity). 

Under   the    name  of  reasoning  phrenasthenias,  I 
designate   the    moral  insanity   of   certain    authors. 


PHEENASTHENIAS.  305 

Strictly  speaking  there  is  no  need  of  giving  a  special 
name  to  the  maladies  of  this  type,  since  they  can  be 
included  among  those  of  the  preceding  class.  Like 
them,  they  are  victims  of  heredity,  essentially  degen- 
erates, and  have  clearly  marked  bodily  and  mental  de- 
fects. The  distinction  between  the  two  is  merely  in 
the  fact  that  only  exceptionally  do  they  have  delus- 
ions, properly  so-called,  and  that  their  vice  of 
organization  reveals  itself  especially  in  perversions  of 
the  sentiments  and  the  affections.  They  are  the 
individuals  who,  with  apparent  full  reason  and 
judgment,  permit  themselves,  in  an  unconsious  and 
frequently  paroxysmal  manner,  to  indulge  in  errors 
of  conduct,  inconsistencies,  excesses,  and  immoral 
acts  that  are  really  pathological,  whence  the  term 
moralty  insane  that  has  been  applied  to  them.  Fun- 
damentally, and  although  apparently  less  insane, 
they  are  more  profoundh^  degenerate  than  the  delu- 
sional cases,  and  they  border  a  more  marked  degree 
of  mental  infirmity,  imbecility. 

Instinctive  Phrenasthenias. 
{The  Criminal  Psycliosis). 

What  has  been  said  above  is  still  more  true  of  the 
individuals  affected  with  instinctive  phrenasthenia, 
in  whom  the  degeneracy  shows  itself  particularly 
by  an  innate  tendency  to  perverse  or  criminal  acts. 

The  born-criminals  of  Lombroso  and  the  Italian 
school  unquestionably  belong  to  this  variety  of  the 
degenerates.    It  would  be  indeed  a  mistake  to  believe 


306  DEGEXEEACIES  OF  EVOLUTION. 

that  there  is  a  special  form  of  insanity  having  for 
its  symptoms  a  tendency  to  crime,  i.  e.,  a  j^ure  crim- 
inal psychosis.  The  proposition  should  be  reversed, 
as  it  is  more  correct  to  sav  that  there  is  a  class  of 
criminals  presenting  clearly  a  more  or  less  evident 
vice  of  organization.  But  whatever  has  been  pre- 
tended, the  somatic  anomalies  of  these  beings  should 
not  be  considered  as  peculiar  to  them.  It  is  possible 
and  even  probable  that  certain  characters  of  degen- 
eracy are  met  with  more  frequently  in  a  determined 
morbid  variety,  comparing  among  themselves  its 
various  members,  and  that  exaggeration  of  the  great 
envergure^  asymmetry  of  the  face,  j)rominence  of  the 
cheek  bones  and  the  superciliary  arches,  increased 
size  of  the  lower  jaw,  the  presence  of  the  sub-occipi- 
tal fossa  and  the  lemurian  appendix,  to  cite  only 
these,  are  especially  marked  in  criminal  degenerates. 
This,  however,  is  no  ground  for  seeing  in  the  degen- 
eracy of  criminals  a  special  teratological  vice  due  to 
a  special  cause,  such,  for  example,  as  the  reversion  to 
the  savage  ancestral  condition.  The  degeneracy  is 
always  one,  and  varied  as  may  be  its  stigmata,  it  is 
none  the  less  identical  in  its  origin  and  consequences. 

The  born-criminal  is  therefore  only  an  instinctive 
degenerate,  just  as  the  insane  persecutor  is  an 
intellectual  and  reasoning  degenerate. 

There  is  much  to  be  said  on  such  a  living  question 
as  that  of  criminal  degenerates,  which,  under  the 
magnificent  influence  of  Lombroso,  has  been  the 
subject,    in    recent   years,    of  so    many   interesting 


MONSTROSITIES. 


307 


memoirs  in  the  different  countries  of  Europe,  not- 
ably in  Italy,  France  and  Russia.  But,  by  a  rather 
curious  scientific  eA'-olution,  the  study  of  the  criminal, 
at  first  purely  anthropological,  has  gradually  taken 
a  new  direction,  and,  enlarging  itself  by  degrees, 
has  now  become  plainly  a  sociological  one.  The 
criminal,  in  fact,  as  has  been  well  said  by  La- 
cassagne,  is  a  microbe  inseparable  from  his  culture 
broth,  the  social  surroundings.  The  complete  study 
of  the  criminal  appertains  therefore,  for  the  present, 
rather  more  to  sociology  than  to  psychiatry,  prop- 
erly speaking,  and  in  the  period  of  investigations 
we  are  passing  through,  we  can  only  refer  the  reader 
to  the  well  known  works  of  Lombroso,  Manouvrier, 
Sergi,  Garofalo,  Tarde,  and  Lacassagne,  which 
include  all  the  data  at  present  known  on  this  subject. 

§  IV.     MONSTROSITIES. 
(Imbecility,  Idiocy,  Cretinism). 

The  monstrosities,  which  represent  the  highest 
degree  of  vices  of  organization  or  mental  infirmities, 
comprise:  imbecility,  idiocy,  and  cretinism. 

Imbecility. 

The  imbeciles  may  be  in  certain  instances,  well 
formed,  vigorous,  and  healthy:  generally,  liowevcr, 
they  exhibit  characteristic  bodily  anomalies. 

Their  cranium,  small  or  voluminous,  is  liable  to 
the    most  varied  malformations  and  asymmetries; 


308  DEGENEEACIES  OF  EVOLUTION. 

their  physiognomy  denotes  their  deficient  intelli- 
gence, and  often  suggests  by  its  general  configura- 
tion, the  appearance  of  an  animal;  the  forehead 
is  low  and  straight,  the  ears  ill  formed  and  badly 
inserted;  the  eyes  are  small,  expressionless,  often 
strabismic;  there  are  also  lisping,  prognathism, 
anomalies  of  the  velum  palati,  the  uvula,  and  nearly 
always  also  of  the  genital  organs,  which  are  some- 
times remarkable  for  their  rudimentary  conditions, 
sometimes,  on  the  other  hand,  from  their  exagger- 
ated size. 

In  a  psychic  point  of  view,  the  imbeciles  possess 
only  a  more  or  less  restricted  intelligence;  they 
leam  to  read,  write,  and  count,  with  difficulty; 
while  susceptible  of  acquiring  a  slight  and  super- 
ficial tincture  in  everything,  they  are  incapable  of 
a  correct  and  consecutive  course  of  conduct  and  of 
doing  anything  in  earnest.  Nevertheless,  some  of 
them,  notably  weak-minded,  though  in  a  slighter 
degree,  have  exhibited  more  or  less  brilliant  artistic 
ability,  great  qualities  of  memory  or  imitation,  and 
often  also  a  certain  vivacity  of  spirit,  a  promptness 
and  shrewdness  of  repartee  which  gives  them  always 
the  last  word  and  puts  the  laughers  on  their  side. 
This  peculiarity  which  is  very  striking  in  them  and 
is  in  maiked  contrast  with  the  profound  deficiencies 
of  their  intelligence,  explains  why  tliey  were  chosen 
in  former  times  as  buffoons  by  kings  whom  they 
brightened  with  their  sallies  and  bon  mots. 

In  a  moral  point  of  view  the   lacunae  are  perhaps 


MONSTROSITIES. 


309 


more  marked  than  in  the  domain  of  the  intellect, 
and  if  these  patients  are  capable  of  showing  to 
varying  extent,  sentiments  and  affections  of  a  low 
order,  they  are  only  the  least  elevated  ones,  and  the 
lower  instincts  that  dominate  them.  The  majority 
are  vain,  gluttonous,  cowardly,  credulous,  idle,  iras- 
cible, inclined  to  venereal  and  alcoholic  excesses  and 
to  acts  of  violence  (Marce) ;  nearly  all  are  given  to 
onanism,  and  some  even  to  unnatural  crimes.  At 
certain  times  they  may  be  seized  more  or  less  sud- 
denly with  melancholic  or  maniacal  attacks,  during 
which  they  are  particularly  liable  to  commit  acts  of 
obscenity,  or  even  arson,  robbery,  suicide,  or  hom- 
icide. When  these  attacks,  which  very  often  assume 
in  them  a  periodical  or  circular  character,  occur 
many  times,  the  patients  soon  fall  into  a  condition  of 
dementia. 

Idiocy, 

Idiocy,  formerly  confoimded  with  all  the  other 
mental  infirmities  and  all  conditions  of  intellectual 
obtunding,  has  been  elucidated  especially  by 
Esquirol,  who  differentiated  it  from  dementia.  His 
classic  definition  is  well  known.  "  The  demented 
man,"  said  he,  "is  deprived  of  the  good  that  he 
formerly  enjoyed;  he  is  a  rich  man  become  poor: 
the  idiot  has  always  lived  in  misfortune  and  poverty." 

Esquirol  recognized  three  degrees  in  idiocy  and 
to-day  also  we  still  admit  generally  two  classes 
of  cases  in  that  condition  of  mental  infirmity:  (1) 


/ 


310 


DEGEXEEACIES  OF  EVOLUTION. 


idiots  of  the  second  degree;  (2)  idiots  of  the  first 
degree,  or  complete  idiots. 

(1).  The  idiots  of  the  second  degree  hold  the 
middle  place  between  the  imbeciles  and  the  complete 
idiuts. 

Physicalh/^  they  present  very  marked  vices  of  con- 
formation in  different  parts  of  the  body.  Their 
stature  is  generally  small;  their  hands  those  of  a 
child,  and  of  ten  presenting  special  peculiarities  (idiot 
hand).  The  head  is  usually  small  and  irregular, 
sometimes,  on  the  other  hand,  it  is  enormous ;  their 
face  lacks  expression ;  deaf-mutism,  strabismus,  con- 
genital fissure  of  the  palate,  anomalies  of  the  ear, 
teeth,  tongue,  genital  organs,  and  various  bodily 
deformities  are  very  frequent  in  them;  they  are  sub- 
ject to  j^eculiar  tics^  to  choreiform  movements,  to 
rumination  {merycisme) ;  they  often  have  paralysis, 
especially  infantile  paraplegia  or  hemiplegia  with 
atrophy  and  contractures;  their  sensibility  is  very 
dull  and  sometimes  almost  abolished ;  and  lastly  they 
are  subject  to  neuropathic  complications  and  epilepsy 
in  particular. 

Intellectually^  their  faculties  are  extremely  limited 
and,  as  it  were,  in  a  rudimentary  condition.  Gener- 
ally they  pronounce  only  a  few  words  or  phrases, 
which  form  their  whole  vocabulary;  they  can  eat 
alone  and  know  how  to  select  their  food ;  they  recog- 
nize those  who  live  with  them,  and  show  some  attach- 
ment to  those  who  care  for  them.  But,  apart  from 
some  isolated  artistic  aptitudes,  not  capable  of  cul- 


MONSTROSITIES. 


311 


tivation,  they  have,  properly  speaking,  no  intelli- 
gence; their  education  is  7iil\  they  hardly  know 
their  age  or  names,  and  are  unable  to  give  the  least 
indication  as  to  the  course  of  j^ears  and  months,  the 
value  of  money,  the  difference  in  colors,  etc.,  etc. 

According  to  Sollier  (1891)  the  psychology  of  the 
idiot  is  summed  up  in  the  more  or  less  complete  ab- 
sence of  the  primordial  faculty :  the  will. 

Morally^  the  sentiments  and  affections  are  alto- 
gether absent  and  are  replaced  by  the  instincts. 
The  sexual  instinct  is  particularly  developed;  the 
majority  of  these  unfortunates  masturbate  in  public 
and  before  their  associates  without  the  least  appear- 
ance of  shame ;  others  commit  paederasty,  run  after 
all  women,  or  exhibit  their  genitals  in  the  street. 
Finally,  these  idiots,  like  the  imbeciles  and  complete 
idiots,  are  Yexj  often  affected  with  epilepsy.  Natur- 
ally passionate,  they  may  be  seized  with  attacks  of 
maniacal  agitation  during  which  the}^  give  utterance 
to  savage  and  inarticulate  cries,  and  give  themselves 
over  to  acts  of  violence  that  are  absolutely  bestial. 

(2) .  In  the  complete  idiots  the  phj^sical  and  men- 
tal development  reaches  its  lowest  limit,  which  is 
shown  by  the  total  absence  of  intelligence,  the  sen- 
timents, sensibility,  and  even  certain  instincts.  The 
majority  are  hideous  appearing,  rachitic,  covered 
with  scrofula,  afflicted  with  all  kinds  of  vices  of 
conformation,  partial  paralyses,  and  contractures, 
choreic  and  convulsive  movements,  automatic  tics^ 
and  very  often  epilepsy.     Many  are   blind,    deaf, 


312 


DEGEKERACIES  OF  EVOLUTION. 


dumb,  depriyed  of  the  senses  of  taste  and  smell, 
absolutely  incapable  of  walking,  dressing  them- 
selves or  feeding  themselves.  Their  physiognomy  is 
stupid,  expressionless,  the  evacuations  are  invol- 
untary, the  saliva  drools  constantly  from  between 
their  half-opened  lips,  raucous  and  inarticulate  cries 
escape  from  their  throats ;  the  second  dentition  does 
not  occur,  no  sign  of  pubert}^  appears :  at  twenty, 
these  unfortunates  seem  only  four  years  old.  Every- 
thing is  reduced  in  them  to  the  accomplishment  of 
the  last  vegetative  functions,  and  the  only  signs  of 
life  they  manifest  are  their  automatic  balancings 
and  their  unconscious  manoeuvres  of  masturbation. 
Such  a  condition  is  incompatible  with  any  long  exis- 
tence, and  these  idiots  of  this  degree  hardly  live 
beyond  twenty-five  or  thirty  years. 

Etiology. — Idiocy  and,  consequently,  the  various 
arrests  of  development  that  we  are  studjdng,  recog- 
nize heredity  as  their  principal  cause,  especially  that 
of  mental  alienation,  epilepsy,  hysteria,  alcoholism, 
syphilis,  and  consanguinity  of  parents.  Even  when 
idiocy  is  not  congenital  but,  as  has  been  said, 
acquired,  heredity  is  nearly  always  the  primary 
cause,  not  directly,  but  indirectly  through  the 
infantile  disorders  such  as  meningitis,  convulsions, 
hydrocephalus,  etc.,  that  it  causes.  Together 
with  heredity,  have  been  noted  as  adjuvant  causes, 
blows,  falls  on  the  head,  compression  of  the  head 
during  labor,  and  also,  the  compression   practiced 


MONSTEOSITIES.  313 

in  certain  countries  to  give  the  heads  of  infants  a 
determined  form. 

Pathological  Anatomy. — The  lesions  suscepti- 
ble of  being  observed  in  cerebral  weaknesses,  and 
notably  in  idiocy,  usually  involve  the  whole  of  the 
head,  and  may  be  divided  into  external  and  internal. 

1.  There  is,  properly  speaking,  no  special  de- 
formity of  the  cranium  peculiar  to  idiocy.  All  de- 
scribed anomalies  maybe  encountered,  from  the  most 
simple  which  manifest  themselves  in  a  simple  diminu- 
tion of  the  cranial  volume  without  changing  its  pro- 
portions, up  to  the  most  complex,  shown  by  the  var- 
ious deformities  known  as  scaphocephaly,  plagio- 
cephaly,  etc.,  etc. 

In  a  general  way,  and  apart  from  those  cases 
where  the  idiocy  is  connected  with  chronic  hydro- 
cephalus, the  most  constant  deformity  is  microceph- 
aly, with  corresponding  diminution  of  the  cranial 
cavity.  The  diameters  most  affected  are  generally 
the  transverse,  so  that,  contrary  to  the  great  major- 
ity of  cretins,  the  idiots  are  more  dolicocephalic 
than  brachycephalic.  The  sutures  sometimes  ossify 
prematurely,  either  throughout  or  by  preference  at 
certain  points;  sometimes,  on  the  contrary,  they 
ossify  only  late  or  not  at  all.  In  this  last  event 
they  are  often  filled  with  a  large  quantity  of 
wormian  bones. 

2.  Excluding  certain  exceptional  cases  in  which 
the  brain  is  more  voluminous  and  heavy  than  nor- 

jjent,  Med,— so. 


314        DEGENERACIES  OP  EYOLUTION. 

mal,  the  diminution  of  the  volume  and  weight  of 
that  organ  is  the  most  constant  and  remarkable 
alteration  in  idiocy.  The  brain  weight  in  idiots 
varies  from  700  to  1,100  grams. 

Besides  this  alteration,  there  are  others,  such  as 
marked  inequality  of  the  hemispheres,  atrophy  of  one 
of  them ;  rudimentary  condition  of  certain  regions, 
especially  the  anterior  lobes;  absence  of  certain 
parts,  such  as  the  corpus  callosum,  the  central 
nuclei,  the  fornix,  etc. ;  various  lesions,  such  as 
hydrocephalus,  porencephaly,  atrophic,  hypertrophic 
and  tuberculous  scleroses,  smoothness,  thinning,  or 
even  absence  of  certain  convolutions,  especially  the 
frontal  ones,  with  greater  or  less  enlargement  of 
the  fissures  and  sulci,  particularly  the  fissure  of 
Sylvius.  Finally,  in  a  histological  point  of  view, 
we  find  various  alterations  of  the  structure  of  the 
nervous  substance,  softening  of  the  gray  matter, 
presence  of  numerous  idiot  cells,  and  also  certain 
anomalies  of  the  cerebral  circulation,  recently 
described  by  M.  Luys. 

Bourneville  distinguishes,  from  an  anatomico- 
pathological  point  of  view,  the  following  forms  in 
idiocy:  (1)  idiocy  symptomatic  of  hydrocephalus 
(hydrocephalic  idiocj^) ;  (2)  idiocy  symptomatic  of 
microcephaly  (microcephalic  idiocy) ;  (3)  idiocy 
symptomatic  of  an  arrest  of  development  of  the  con- 
volutions; (4)  idiocy  symptomatic  of  a  congenital 
malformation  of  the  brain  (porencephaly,  absence  of 
corpus  callosum,  etc.);    (5)  idiocy  symptomatic  of 


MOI^'STROSITIES.  315 

hypertrophic  or  tuberculous  sclerosis;  (6)  idiocy 
symptomatic  of  atrophic  sclerosis :  (a)  sclerosis  of  one 
or  both  hemispheres ;  (b)  sclerosis  of  one  lobe  of  the 
brain ;  (c)  sclerosis  of  isolated  convolutions ;  (d)  scler- 
osis chagrinee  (like  shagreen)  of  the  brain  (?) ;  (7) 
idiocy  symptomatic  of  chronic  meningitis  or  menin- 
gito-encephalitis  (meningitic  idiocy) ;  (8)  idiocy  with 
pachydermic  cachexia,  or  myxosdematous  idiocy 
connected  v/ith  absence  of  the  thyroid  gland.  This 
last  form  is  also  called  cretinoid  idiocy,  cretinoid 
pachydermia,  or  sporadic  cretinism.  It  will  be 
noticed  later  on  in  the  remarks  on  cretinism. 

Diagnosis.  Prognosis. — The  diagnosis  of  the 
monstrosities  is  generally  very  easy,  as  they  can 
hardly  be  mistaken  for  dementia.  The  only  point 
consists  in  determining  the  exact  degree  of  the  arrest 
-  of  development,  since,  as  has  been  said,  the  limits 
between  the  different  varieties  of  cerebral  infirmities 
are  not  clearly  defined. 

As  to  the  prognosis,  it  is  not  necessary  to  dilate 
upon  its  gravity.  Complete  idiocy  is  incompatible 
with  a  long  life.  Incomplete  idiocy  and  imbecility 
are  only  susceptible  of  a  slight  modification  under 
the  influence  of  special  treatment. 

Treatment. — Thanks  to  the  efforts  of  Belhomme, 
Felix  Voisin,  Seguin,  Delasiauve,  Bourneville,  etc., 
a  therapeusis  and  a  special  pedagogy  has  been  grad- 
ually formed  for  idiots.     This  treatment,  the  special 


316  DEGEXEEACIES  OF  EVOLUTION. 

rules  of  wMcli  cannot  be  given  here,  consists  in  the 
wisely  combined  employment  of  hygienic,  moral, 
and  intellectual  agencies. 

Some  recent  trials  of  craniectomy  (Lannelongue, 
of  Paris)  in  idiots  with  premature  synostosis  of  the 
cranial  bones  seem  to  have  given  good  results. 
This  intervention  of  surgery  in  certain  special  cases 
of  idiocy  may  possibly  have  a  certain  future  use- 
fulness. 

Cretinism. 

Defixitiox. — We  designate  under  the  name  of 
cretinism,  an  arrest  of  development  of  the  organism, 
with  special  features  involving  particularly  the  phys- 
ical constitution,  of  endemic  origin,  and  habitually 
accompanied  with  goitre. 

The  cretins  are  usually  divided  into  three  classes, 
representing  the  three  progressive  degrees  of  degen- 
eracy: 1,  the  cretinoid  or  sluggards;  2,  the  semi- 
cretins;  and  3,  the  cretins. 

1.  The  cretinoids  are  essentially  characterized: 
intellectually,  by  the  sj^mptoms  of  more  or  less  com- 
plete imbecility ;  physically,  by  the  signs  of  the  first 
degree  of  the  cachexia.  These  signs  consist  mainly 
in  the  flattening  of  the  nose,  the  size  of  the  mouth,  the 
earthy  color  of  the  skin,  the  pufHness  of  the  face,  the 
bad  implantation  and  condition  of  the  teeth,  a  gen- 
eral arrest  of  development  of  the  organism,  more 
or  less  pronounced,  and  lastly  in  the  existence  of  a 
goitre  of  varying  size.    The  head  is  generally  rather 


MONSTROSITIES.  317 

large,  and  clearly  brachycephalic  in  type,  as  is  the 
case  with  most  cretins.  According  to  Cerise,  the 
cretinoids  have  always  also  a  rather  marked  fronto- 
occipital  depression.     They  are  apt  in  reproduction. 

2.  The  semi-cretins  differ  especially  from  the  cre- 
tinoids in  the  much  more  marked  degree  of  the  ex- 
ternal signs  of  the  cachexia.  The  difference  is  slighter 
as  regards  the  mental  condition ;  moreover,  the  major- 
ity of  the  cretins  are  not  properly  idiots,  and  in 
some  of  them  the  intellectual  deficiencies  are  not  at 
all  proportional  to  the  physical  degeneracy.  The 
serai-cretins  are  generally  squat  in  figure,  their  limbs 
stumpy,  the  joints  large  and  swollen,  the  neck  short 
and  thick;  at  other  times  they  are,  on  the  other 
hand,  thin  and  slim ;  their  head  is  large,  and  partic- 
ularly broad,  their  eyes  bulging,  and  half  covered  by 
the  swollen  lids;  their  cheeks  and  lips  are  flaccid 
and  pendant,  their  teeth  carious  and  badly  implanted ; 
their  skin  is  clayey,  their  goitre  voluminous.  Their 
gait  is  vacillating  and  irregular ;  their  sphincters  are 
relaxed ;  their  respiration  stertorous  and  wheezing ; 
their  tongues  hanging  between  the  open  lips  drip 
with  saliva.  Their  sensibility  is  very  obtuse,  their 
intelligence  very  limited,  and  their  speech,  very 
imperfect,  is  limited  most  often  to  a  few  monosjdla- 
bles.  Quite  unlike  the  full  cretins,  thaj  have  vol- 
uminous genital  organs  and  nearly  always  give 
evidence  of  a  great  salacity. 

3.  The  complete  cretins,  entirely  lacking  in  in- 
tellectual and  reproductive  faculties,  as  well  as  of 


318  DEGEXEEACIES  OP  EVOLUTION. 

reproductive  power,  endowed  only  with  vegetative 
faculties,  represent  the  highest  degree  of  cretinoid 
degeneracy  (Marce).  They  resemble  young  infants 
and  have,  like  them,  the  chest  weak,  the  abdomen 
prominent,  and  their  teeth  are  of  the  first  dentition. 
The  goitre  when  present  is  slight,  which  is  explained 
b}^  the  absence  of  puberty.  Their  genital  organs 
are  altogether  rudimentary.  They  can  hardly  walk 
and  sometimes  remain  in  a  condition  of  absolute  im- 
mobility. All  their  senses  are  obtunded,  and  some- 
times nil;  their  voice  is  reduced  to  raucous  cries  or 
to  gruntings  that  have  nothing  human  in  them. 

Etiology. — It  appears  from  the  numerous  works 
on  cretinism  that  this  form  of  degeneracy  recognizes 
no  single  cause,  but  that  it  is  the  result  of  many 
cumulative  ones. 

Some  of  these  are  found  in  the  geological  consti- 
tution of  the  soil,  the  altitude,  the  topography,  the 
chemical  constitution  of  the  air  and  water.  It  is  a 
well  known  fact  that  cretinism  is  endemic  especially 
in  certain  narrow  valleys  of  the  Alps,  the  Pyrenees, 
of  Auvergne,  Scotland,  Tyrol,  New  Grenada,  and 
Hindostan.  In  France,  the  department  of  Haute- 
Savoie  is  that  which  furnishes  the  most  cretins. 
These  valleys  are,  for  the  most  part,  contracted; 
humid,  deprived  of  air,  light  and  sun,  and  at  nearly 
an  equal  altitude  above  the  sea.  Their  villages  are 
built  against  the  sides  of  the  mountains  and  the 
houses  are  low  and  damp.     The  soil  is  magnesian, 


MONSTROSITIES.  319 

the  waters  coming  from  the  melting  snows  is  hard, 
badly  aerated,  mixed  with  silex,  charged  with  lime 
salts,  and  lacking  in  bromine  and  iodine.  Moreover, 
in  the  infected  villages  the  hygienic  conditions  are 
very  poor  and  the  iinfortunate  inhabitants  live  in  a 
very  repulsive  state  of  uncleanliness. 

Together  with  these  causes  which  exist  in  all 
countries  where  the  cretinous  degeneration  prevails 
and  which  make  it  there  endemic,  are  to  be  considered 
individual  causes  consisting  especially  in  heredity, 
consanguineous  marriages,  etc.  Whether  the  goit- 
rous and  cretinous  cachexias  are  the  same  or  not,  it 
is  none  the  less  true  that  the  cretins  represent  the 
most  degraded  products  of  a  race  that  begins  with 
goitre  and  that  the  goitrous  and  the  cretins  mutually 
engender  each  other. 

Nature. — It  is  not  fully  agreed  as  to  the  nature 
and  the  ultimate  cause  of  cretinism.  One  of  the 
most  accepted  theories  consists  in  considering  cretin- 
ism as  a  diffuse  oedematous  hydrocephalus,  produced 
by  the  compression  exerted  by  the  thyroid  or  thy- 
mus gland  on  the  cervical  vessels.  This  theory, 
nevertheless,  is  open  to  many  objections,  the  chief 
of  which  is  that  certain  cretins,  the  complete  cretins, 
are  either  not  goitrous  or  only  slightly  so.  It  is  more 
probable  that  cretinism  is  the  result,  not  of  a  mere 
mechanical  compression,  but  of  the  abolition  of  the 
physiological  function  of  the  thyroid  gland. 

However  it  may  be,  if  these  theories  are  correct, 


320  DEGEIfERACIES  OF  EVOLUTION. 

it  only  places  the  difficulty  a  little  farther  back, 
since  it  will  always  be  necessary  to  explain  either 
the  origin  of  the  goitre  or  of  the  hypertrophy  of 
the  thymus  in  the  cretins. 

There  is  nothing  special  in  the  pathological  ana- 
tomy of  the  cretins.  It  consists,  the  same  as  in 
idiots,  of  decrease  of  volume  and  weight  of  the  brain, 
narrowing  of  the  cranial  foramina,  especially  the  oc- 
cipital, and  atrophy  of  many  parts,  notably  of  the 
convolutions. 

Treatment, — The  most  important  matter  relative 
to  the  management  of  cretinism  is  prophylaxis. 
This  consists  in  the  application  of  hygienic  means  to 
counteract  the  general  causes  of  the  degeneracy. 
It  is  well  known  that  with  the  opening  of  roads,  the 
sanitation  of  the  villages,  the  procurement  and  control 
of  proper  sources  of  drinking  water,  and  lastly,  with 
the  diminution  of  poverty  in  the  affected  villages, 
goitre  and  cretinism  have  both  decreased  in  frequency. 
The  same  will  be  true  as  regards  properly  selected 
marriages  that  can,  in  a  measure,  combat  successfully 
the  hereditary  element. 

As  to  curative  treatment,  it  consists  in  the  removal 
of  cretin  infants  and  their  transfer  to  healthy 
regions,  in  an  appropriate  bodily  and  mental  train- 
ing, and,  finally,  in  the  use  of  iodine  and  its 
preparations. 

Sporadic  cretinism.  Cretinoid  idiocy.  Idiocy 
with   pachydermic     cachexia.       Cretinoid  pachy- 


MONSTROSITIES.  321 

dermy.  Myxoedematous  idiocy. — Under  these  va- 
rious designations  there  has  been  described  a  physical 
and  intellectual  arrest  of  organic  development, 
offering  the  general  features  of  cretinism,  but  not, 
like  it,  arising  from  an  endemic  condition.  The 
only  special  peculiarities  really  belonging  to  this 
condition  seem  to  be  the  almost  constant  existence 
of  pseudo- lipomatous  masses  located  especially  in 
the  sub-clavicular  hollows,  and  in  the  almost  pachy- 
dermatous or  myxoedematous  appearance  of  the  sub- 
jects. 

M,  Bourneville,  who  has,  in  recent  years,  brought 
together  under  the  name  of  myxoedematous  idiocy 
the  most  of  the  known  cases  of  sporadic  cretinism, 
attributes  this  form  of  degeneracy  to  the  absence 
of  the  thyroid  gland.  This  opinion,  which  has  long 
been  advanced  in  England,  particularly  by  Curling 
in  1850  and  Hilton  .Fagge  in  1871,  is  not  absolutely 
correct,  as,  in  a  case  reported  by  Bucknill  and  Tuke 
and  in  another  reported  by  M.  Arnozan  and  myself 
in  1888,  there  was  an  evident  goitrous  hypertrophy. 
Instead  of  saying  with  Hilton  Fagge,  that  ' '  goitre  is 
never  present  in  sporadic  cretinism,"  or  with 
Bourneville  that  ' '  myxoedematous  idiots  do  not  have 
the  thyroid  gland  and  therefore  no  goitre,"  it  is 
better  to  conclude,  as  Robinson  did  in  1886,  that  in 
sporadic  cretinism  ' '  the  thyroid  gland  is  either  ab- 
sent or  affected  with  some  organic  alteration." 

Formulated  in  these  terms,  the  opinion  that 
attributes  a  thyroidian  origin  to  sporadic  cretinism 


322 


DEGENERACIES  OF  EVOLUTION. 


is  very  plausible,  and  has  an  important  confirmation 
in  tlie  probable  pathogeny  of  certain  conditions, 
such  as  mj^xoedema,  cachexia  strumipriva,  and  ex- 
perimental cretinism,  regarded  with  reason  by  Ord 
and  some  other  authors  ' '  as  forming  Avith  cretinism 
a  single  disorder,  that  has  for  its  direct  cause  the 
loss  of  the  functions  of  the  thyroid  gland." 

The  most  recent  researches  on  this  subject  au- 
thorize us  to  believe  that  the  thyroid  body  is  a 
vascular  gland,  the  secretion  of  which  assists  in  the 
elimination  or  neutralization  of  certain  toxic  prod- 
ucts of  denutrition.  Cretinism  and  allied  states 
(sporadic  and  experimental  cretinism,  cachexia 
strumipriva,  myxoedema),  will  therefore  have  a 
common  origin,  and  be  due  to  an  intoxication  of 
tJie  organism  from  the  absence  or  suppression  of  the 
function  of  the  thyroid  gland. 

Supporting  themselves  on  these  facts,  Horsley, 
Lannelongue,  Bettencourt-Rodriguez,  and  some 
others,  have  recently  tried  to  graft  the  thyroid 
gland  of  the  sheep  into  the  subjects  of  myxoedema 
and  cachexia  strumipriva,  but  this  operation  has  not 
yet  given  satisfactory  results.* 


*  Since  the  above  was  written,  numerous  observations  have  been 
reported  in  which  favorable  results  have  been  apparently  obtained 
by  thyroid  transplantation  find  especially  by  the  internal  and  hypo- 
dermic administration  of  thyroid  extract  in  myxoedema.— (Tuans- 
latob). 


SECOND  GROUP. 

DEGENERACIES   OF  INVOLUTION. 

(Disorganizations), 


SIMPLE  DEMENTLl. 

Dementia  is  an  acquired  cerebral  infirmity,  charac- 
terized by  failure  of  the  intellectual  and  moral  facul- 
ties. "  It  has  long  been  confounded  with  idiocy  and 
with  stupor,  which  Esquirol  considered  to  be  an 
acute  dementia.  It  is  not  necessary  to  restate  here 
that  this  last  is  due  to  an  obtunding,  and  not  to  a 
weakening  of  the  intelligence. 

Etiology. — Dementia  is  the  consequence  of  a 
host  of  different  causes.  It  is  divided  into  primary 
and  consecutive  forms,  according  as  it  appears  all  at 
once  of  itself,  or  follows  another  disorder  of  which 
it  is  then  the  final  stao^e.  This  is  much  the  most 
common  occurrence,  so  much  so  that  M.  Ball  has 
said  that  dementia  constituted  2,  point  of  arrival 
rather  than  2, point  of  departure.  Primary  dementia 
is  that  which  is  due  to  age  (senile  dementia),  or  to 
organic  changes  of  the  brain  (apoplectic,  paralytic 
dementia,  etc.),  consecutive  dementia  is  that  which 
forms  the  termination  of  the  various  insanities 
(vesanic  dementia),  epilepsy,  alcoholism,  arrests   of 


324  DEGENERACIES  OF  INVOLUTION. 

development,  and,  in  a  general  way,  all  the  disorders 
that  end  at  the  expense  of  the  mental  and  moral 
faculties. 

Description. — I  must  confine  myself  here  to 
describing  simple  dementia,  that  is,  the  acquired 
cerebral  infirmity  constituted  by  intellectual  enfeeble- 
ment.  This  is  the  skeleton  of  dementia,  the  com- 
mon basis  of  all  its  varieties ;  as  regards  the  peculiar- 
ities, delusional,  etc.,  that  it  presents  in  certain 
cases,  they  are  only  superadded  symptoms  that  will 
be  noticed  in  connection  with  the  various  patholog- 
ical conditions  of  which  they  are  the  consequence. 
The  type  of  simple  dementia  is  represented  by  senile 
dementia  without  delusions. 

Three  periods  can  be  distinguished  in  dementia : 
(1)  an  initial  period ;  (2)  a  middle  stage;  (3)  a  term- 
inal period. 

1.  Initial  Period, — It  is  exceptional  to  see  demen- 
tia appear  suddenly.  Generally  its  beginning  is 
insidious,  and  the  mental  weakness  is  already  more 
or  less  profound  when  it  is  recognized.  First  of  all, 
there  is  a  more  or  less  decided  incapacity  for  work, 
a  lack  of  precision  and  lucidity  in  business,  in  the 
ideas  and  judgments,  also  errors  in  figures  and 
calculations.  Soon  defects  begin  to  appear  in  the 
memory  which  is,  usually,  the  first  faculty  affected. 
The  amnesia  first  involves  only  recent,  and  conse- 
quently^ the  least  adherent  (Kussmaiil)  recollections, 
while,  on  the  other  hand,  the  older  ones  come  up  in 


SIMPLE  DEMENTIA.  325 

crowds  and  have  a  special  revivication.  The  patients 
forget  what  they  have  done  and  said,  they  lose  their 
objects,  they  do  not  recollect  what  they  intended  to 
do  when  they  have  their  work  half  done.  When 
they  talk,  they  constantly  repeat,  forgetting  names 
and  words,  the  same  stories  in  the  details  of  which 
they  wander  losing  every  minute  the  thread  of  their 
discourse.  Their  character  changes  at  the  same  time, 
and  as  regards  this  feature,  we  can  recognize  two 
classes :  the  apathetic  and  the  excited;  the  ones  placid 
and  good  natured,  the  others  irritable  and  cross- 
grained  to  excess.  Generally,  at  this  time,  they 
begin  to  lose  their  good  manners,  their  habits 
and  good  tone,  and  to  offend  in  their  talk,  their 
gestures,  and  dress  against  the  most  elementary 
rules  of  politeness  and  decency. 

2.  Middle  Period. — After  a  longer  or  shorter 
time,  the  patients  become  absolutelj^  incapable  of 
serious  and  sustained  employment,  and  their  demen- 
tia makes  notable  progress.  From  recent  facts,  the 
amnesia  extends  to  ideas,  words,  scientific  or  profess- 
ional notions,  to  acquired  languages,  and  spares  only 
the  first  acquisitions  of  the  earliest  ages,  so  that  it 
perfectly  justifies  the  popular  expression  "to  fall 
into  infancy."  Hence  results  a  puerility  of  ideas 
and  language,  a  progressive  diminution  of  the 
sentiments  and  affections  which  makes  the  dement  a 
regular  infant,  credulous,  without  will  power,  excess- 
ively mobile,  forgetful  of  the  simplest  matters  and 
incapable    of    self-control.     As    regards    speech  he 


326 


DEGENERACIES  OF  INVOLUTIOIf. 


becomes  incoherent,  not  like  the  maniacs,  in  whom 
this  is  the  effect  of  an  excessive  mental  activity  and 
is  purely  ellij^tical,  but  in  consequence  of  loss  of 
memory  of  words  and  expressions  to  employ.  It  is 
verbal  incoherence,  a  species  of  characteristic 
aphasia.  The  same  trouble  as  with  speech  occurs 
with  writing. 

In  a  still  more  advanced  stage  the  demented 
patient  is  reduced  to  the  condition  of  an  automaton, 
and  lives  in  the  most  complete  unconsciousness.  It 
is  a  curious  fact,  nevertheless,  that  although  he  has 
forgotten  everj^thing,  even  to  the  number,  age,  and 
names  of  his  children,  even  his  property,  he  can  still 
sometimes  carry  on  perfectly  well,  as  by  a  sort  of 
habit,  more  or  less  difficult  occupations  or  distract- 
ions, such  as  reading  papers,  playing  cards,  checkers, 
billiards,  etc.  His  speech  at  the  same  time  is  pure 
nonsense  without  any  significance  whatever. 

There  are  also  some  physical  peculiarities  to  be 
described :  thus,  the  majority  of  the  dements  take  on 
flesh  and  the  organic  functions  are  carried  on  in  them 
with  very  great  regularity.  It  appears  as  if  the  in- 
tellectual and  the  phj^sical  existence  have  become  al- 
together independent  of  each  other.  On  the  other 
hand  sleep  is  light,  short,  and  often  hardly  occurs. 
In  some  cases,  especially  in  those  where  the  dementia 
is  connected  with  an  organic  cerebral  disorder, 
paralysis  of  the  sphincters  soon  appears. 

3.  Terminal  Period. — This  is  formed  by  an 
almost  complete  obliteration  of  the  intelligence,  and 


SIMPLE  DEMENTIA. 


327 


by  the  progress  of  the  organic  cachexia.  In  a  mental 
and  moral  point  of  view,  the  dement  is  at  this  time 
in  the  same^  condition  as  the  idiot ;  nothing  is  as  it 
formerly  was.  At  the  same  time  he  loses  flesh  and 
appetite,  becomes  altogether  untidy,  and  ends  by 
dying  in  a  more  or  less  complete  state  of  decrepitude, 
either  from  some  cerebral  or  visceral  disorder,  or  in 
consequence  of  trophic  disorders  or  the  progress  of 
the  cachexia. 

Duration.  Pathological  Anatomy. — Simple 
dementia  may  continue  for  a  longer  or  shorter  period ; 
generally  its  evolution  is  very  slow  and  continues  over 
many  years.  The  lesions  vary  according  to  the  cause 
of  the  dementia.  It  may  be  said,  nevertheless,  that 
in  a  general  way  the  dementia  corresponds  to  a  cere- 
bral atrophy  and  to  degenerative  changes  of  the  nerve 
centres. 

Treatment. — The  treatment  of  dementia  can  be 
only  palliative.  In  simple  cases  it  is  limited  to 
hygienic  and  moral  attentions,  the  emploj^ment  of  a 
regular  surveillance,  the  use  of  certain  medicines  to 
ward  off  complications.  When  the  mental  enfeeble- 
ment  is  accompanied  with  delusions,  and  especially 
if  with  pathological  acts,  it  is  often  needful  to  have 
recourse  to  sequestration. 


SECOND  SECTION. 

SECONDARY     CONDITIONS     OF     MENTAL 
ALIENATION. 

(Associated  or  Symptomatic  Insanities). 

The  associated  or  symptomatic  insanities  being, 
as  has  been  shown  in  our  classification,  only  the 
result  of  the  combination  of  a  simple  generalized 
insanity,  mania  or  melancholia,  with  any  process 
whatever,  physiological  or  pathological,  of  the  or- 
ganism, we  might,  strictly  speaking,  dispense  with 
making  them  a  special  study.  It  is  advisable,  how- 
ever, for  the  sake  of  completeness,  to  sketch  broadly 
their  principal  characters,  laying  stress  more  par- 
ticularly on  such  of  them  as  by  their  frequency  and 
their  importance  are  brought  especially  under  the 
notice  of  the  practitioner. 

In  our  description  we  shall  follow  the  order  of  the 
table  here  presented,  in  which  the  symptomatic 
insanities  are  grouped,  according  to  analogies  of 
associations,  under  their  usual  designations.  But  it 
must  be  understood  that  this  table  is  only  an  annex 
to  our  classification,  that  is  not  indispensable,  a 
synoptical  list,  intended  simply  to  assist  the  memory, 
and  to  receive  in  their  places  all  the  new  varieties  of 
associated  insanities  as  they  are  recognized. 


ASSOCIATED  INSANITIES. 


529 


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330 


ASSOCIATED  INSANITIES. 


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Cbapter  ITf . 

INSANITY    ASSOCIATED     WITH     PHYSIO- 
LOGICAL CONDITIONS. 

(Sympathetic  Insanity). 

I. — Insanity  of  Infancy  and  Puberty.  II. — Insanity 
OF  Old  Age.  III.— Insanity  of  Menstruation.  IV. — 
Insanity  op  Pregnancy.  V. — Insanity  of  the  Meno- 
pause. 

§1.     INSANITY   OF  INFANCY  AND  PUBERTY. 
(Hebephrenia.    Pubescent  Insanity). 

Insanity  of  Infancy. — Insanity  is  very  rare  in 
early  infancy  and  it  is  met  with  only  exceptionally 
before  puberty.  When  encountered,  it  is  usually 
observed  in  children  with  a  very  strong  hereditary 
tendency,  and  it  shows  itself  in  them  by  terrors, 
nightmares,  nocturnal  delirium,  visual  hallucinations, 
especially  by  morbid  impulses  of  a  more  or  less 
dangerous  character,  and  only  rarely  by  a  maniacal 
or  melancholic  condition. 

Insanity  of  Puberty. — Puberty  is  a  critical 
period  of  human  life,  and  many  predisposed  and 
nervous  children  show  various  disturbances  of  the 
emotions  and  the  intellect  at  this  time. 


332   rN"SANITY  WITH  PHYSIOLOGICAL  CONDITIOKS. 

The  mental  disorders  incident  to  puberty  are  ex- 
tremely varied,  and  it  is  not  possible  to  include  them 
all  under  a  single  head,  as  has  been  attempted  by  the 
Germans  who  have  described  them  under  the  name  of 
hebephrenia. 

Sometimes  it  is  a  simple  depression,  more  or  less 
acute,  with  a  tendency  to  solitude,  moroseness,  exces- 
sive timidity,  confused  bashf ulness,  vague  longings, 
tears  and  sadness ;  sometimes,  on  the  contrary,  there 
is  a  varying  degree  of  excitement,  showing  itself  in 
an  incessant  activity,  turbulence,  insomnia,  continual 
tricks  and  annoj^ances,  dissimulations  and  falsehoods ; 
and  in  a  more  advanced  stage  the  depression  becomes 
lypemania  or  hypochondria  having  for  its  subject  the 
novel  phenomena  that  appear  in  the  sexual  functions, 
which  surprise,  alarm,  and  torment  the  patients, 
especially  boys,  sometimes  to  the  extent  of  arousing 
in  them  a  very  marked  suicidal  tendency.  The 
excitement  when  it  exists  may  become  agitation,  the 
roguishness  actual  viciousness  with  pride,  presump- 
tion, evil  tendencies,  cruelty,  especially  to  animals, 
impulses  to  theft,  arson  and,  still  more,  to  homicide. 
With  these  bad  tendencies  there  are  also  observed 
occasional  acts  of  extraordinary  bravery  that  arouse 
the  greatest  admiration,  and  are  due  to  no  other 
motive  than  the  desire  to  do  something.  Under  the 
influence  of  this  temporary  impulse,  young  men  show  a 
disdain  for  danger,  at  which  they  are  later  themselves 
astonished. 

These,  however,  are  only  transitory  disturbances, 


INSANITY  OF  PUBERTY.  333 

the  mere  oscillations  of  a  forming  character  seeking 
its  equilibrium.  Other  more  serious  symptoms  may- 
appear  and  produce  an  actual  condition  of  mental 
alienation.  These  are  delusiv^e  conceptions  which, 
in  these  cases,  often  take  on  an  erotico-mystic  or  re- 
ligous  type,  and  reveal  themselves  by  fear  of  the 
'devil,  of  hell,  of  demoniacal  possession,  of  damna- 
tion, by  bizarre  sexual  ideas,  by  platonic  and  mystic 
loves  for  imaginary  beauties  that  often  lead  to  habits 
of  masturbation.  The  rtialaclie  du  doute  may  also 
be  observed.  Some  times  there  are  nocturnal  terrors, 
and  nightmares,  and  even  actual  hallucinations  involv- 
ing mostly  the  visual  sense. 

The  insanity  of  puberty  seems  to  take  the  depres- 
sive rather  more  than  the  maniacal  form,  and  it 
manifests  itself  by  preference,  as  remarked  by  Mairet 
(1889),  in  melancholic  stupor  with  attacks  of  agita- 
tion. In  all  cases  it  localizes  itself  much  more  in  the 
moral  sphere  and  in  that  of  action  than  in  the  purely  in- 
tellectual one,  that  is  it  shows  itself  more  in  morbid 
acts  and  impulses  than  in  delusions.  The  morbid 
impulsions  in  pubescent  insanity  impel  the  patients 
to  dangerous  and  criminal  acts,  and  many  of  the 
misdemeanors  and  crimes  committed  by  young  per- 
sons at  this  period  of  their  lives,  have  no  other  cause 
than  a  mental  disorder  connected  with  the  appear- 
ance of  puberty. 

However  certain  German  authorities  consider  it, 
the  insanity  of  puberty  is  not  usually  of  serious  im- 
port, and  it  disappears  with  the  cessation  of  the  crit- 


334   INSANTTY  WITH  PHYSIOLOGICAL  CONDITIONS. 

ical  period  that  gave  it  rise,  unless  it  has  its  source 
in  a  pronounced  heredity,  in  which  case  it  is  only  the 
first  stage  of  an  intellectual  degeneracy  or  an  incur- 
able dementia. 

It  is  hardly  necessary  to  say  that  the  mental 
disturbances  developed  under  the  influence  of  puberty 
are  manifested  much  more  commonly  in  young 
women  than  in  boys.  We  know,  indeed,  that  nubility 
in  the  former  is  always  a  perilous  period,  and  that 
the  various  stages  of  sexual  life  affect  the  female 
more  pi'ofoundly  than  the  male.  On  the  other  hand, 
it  appears  that  hebephrenia  is  a  less  serious  disorder 
in  the  female  sex,  which  is  possibly  explainable  by 
the  fact  that  when  menstruation  is  once  established 
aud  regular,  it  sets  up  in  the  girl  a  sort  of  salutaiy 
derivation  that  contributes  powerfully  to  the  re- 
establishment  of  the  mental  equilibrium. 

Mairet  considers  choreic  insanity  as  a  simple 
variety  of  pubescent  insanity  in  which  the  delirium 
and  the  chorea  are  both  syndromes  of  the  same  pro- 
cess: puberty.  This  view  is  certainly  not  appli- 
cable to  all  cases ;  and  we  will  therefore  continue,  in 
accordance  with  most  of  the  authorities,  to  describe 
choreic  insanity  by  itself.  It  would  be  more  correct 
to  refer  the  insanity  of  masturbation  to  the  insanity 
of  puberty.  According  to  Spitzka,  who  has  made 
it  a  special  study  (1888),  the  insanity  of  masturba- 
tion is  five  times  more  frequent  in  males  than  in 
females,  and  occurs  ordinarily  between  the  ages  of 
thirteen  and  twenty.     It  is  manifested  physically  by 


rN'SANITY  OF  OLD  AGE.  335 

a  general  exhaustion  of  the  system,  with  anaemia  of 
the  brain,  and  digestive  and  circulatory  disturbances, 
and  mentally,  by  obtuseness,  alternations  of  depres- 
sion and  exaltation  with  a  permanent  ground  work  of 
sadness,  that  usually  passes  into  profound  melan- 
cholia, and  finally  into  dementia. 

The  treatment  of  the  insanity  of  puberty  should 
be  at  once  prophylactic  in  predisposed  children, 
moral,  hygienic  and  medicinal.  Quietness  of  mind, 
the  avoidance  of  religious  subjects  and  of  reading 
matter  capable  of  exciting  the  imagination,  travel, 
recreation,  gymnastics,  hydrotherapy,  sedatives, 
and,  when  required,  emmenagogues,  sum  up  the 
principal  resources  of  treatment  in  such  cases. 

§  II.     INSANITY  OF  OLD  AGE. 
(Senile  Insanity). 

The  insanity  of  old  age,  or  senile  insanity,  is  that 
which  occurs  from  advance  of  years.  It  recognizes 
for  its  main  predisposing  cause,  heredity,  especially 
cerebral  heredity ;  and  as  its  principal  exciting  causes, 
alcoholism,  syphilis,  great  excesses,  and  misfortunes. 
Fiirstner,  who  has  made  a  special  study  of  the 
psychic  disorders  of  old  age  (1888),  classes  them  in 
three  groups :  (1)  simple  senile  psychoses ;  (2)  senile 
psychoses  with  simple  dementia ;  (3)  senile  psychoses 
with  cerebral  dementia. 

The  simple  senile  psychoses  are  those  in^which 
the  insanity  is  not  accompanied  by  intellectual   en- 


336    INSA^SriTT  WITH  PHYSIOLOGICAL  CONDITIONS. 

f eeblement.  It  is  then  a  common,  more  or  less  acute 
attack  of  mania  or  melancholia.  The  maniacal  form, 
much  the  least  frequent,  is  essentially  curable ;  the 
melancholic  often  due  to  a  homologous  and  homo- 
chronous  heredity  (Regis),  affects  by  preference  the 
anxious  type,  and  almost  invariably  terminates  in  the 
chronic  form. 

The  senile  psychoses  with  simple  dementia  are 
those  in  which  the  insanity  is  associated  with  a  con- 
dition of  mental  weakness  without  corresponding 
somatic  lesions.  It  is  a  combination  of  an  attack 
of  mania  or  melancholia  with  simple  dementia,  such 
as  has  been  described  in  the  preceding  pages.  It 
is  generally  met  with  as  a  sub-acute  melancholia 
with  ideas  of  persecution.  These  last  are  in  these 
cases,  necessarily  absard  and  puerile  from  the  co- 
existing dementia.  The  patients  almost  always 
think  tliat  some  one  has  a  design  against  them, 
but  especially  that  they  are  to  be  robbed;  this  is 
their  ruling  idea.  Under  the  influence  of  this  fear 
they  rise  in  the  night,  hide  everything  they  have  in 
places  where  later  they  are  themselves  unable  to  find 
them,  they  barricade  themselves  in  their  houses  and 
in  their  rooms,  and  go  so  far,  as  it  were  automatic- 
ally, as  to  accumulate  in  their  night  vessels,  their 
sheets,  blankets,  and  garments. 

There  may  be  also  hallucinations  of  sight  or  hear- 
ing, but  confused  and  rudimentary  as  they  always 
are  in  demented  conditions. 

There  is  very  little  sleep  or  none  at  all ;  nocturnal 


INSANITY  OF  OLD  AGE. 


337 


noisiness  and  excitement  are  nearly  constant  in  these 
patients.  Their  actions  all  carry  the  stamp  of  de- 
mentia. They  are :  absurd  and  infantile  thefts,  like 
those  of  general  paralytics,  but  even  more  foolish ; 
sudden  and  causeless  fits  of  passion,  ridiculous  and 
heedless  attempts  at  suicide ;  there  are  also  especially 
libidinous  actions,  obscene  exhibitions  of  themselves 
in  23ublic,  attemps  at  rape,  unnatural  crimes,  all  result- 
ing from  lack  of  conscience  and  absolute  loss  of  the 
feeling  of  modesty. 

The  senile  psychoses  with  cerebral  dementia  are 
those  in  which  the  insanity  is  associated,  not  with 
simple  mental  enfeeblement,  but  with  the  bodily  and 
mental  symptoms  of  loss  of  power  due  to  a  more  or 
less  diffuse  lesion  of  the  nervous  centres,  i.  e.,  what 
is  called  organic  or  apoplectic  dementia.  This  will 
be  again  referred  to  later  on  when  discussing  this 
last,  which  does  not  fall  in  any  absolute  fashion 
into  the  category  of  senile  dementia. 

With  the  exception  of  the  simple  insanities,  those 
of  the  first  class,  which  are  curable,  the  maniacal 
form  in  particular,  senile  insanity  is  recovered  from 
only  exceptionally.  It  is  almost  always  necessary  to 
have  recourse  to  isolation  of  tlie  patient  in  order  to 
protect  him  from  the  dangers  to  which  his  delirium 
and  his  dementia  expose  him.  The  treatment,  prop- 
erly speaking,  is  comprised  in  the  medication  for  the 
symptoms.  It  consists  chiefly  in  intestinal  deriva- 
tion and  the  re-establishment  of  sleep  by  means  '  of 
the  appropriate  agents, 


338    rs'SANITY  WITH  PHYSIOLOGICAL  CONDITIONS. 

§  m.     INSANITY  OF  MENSTRUATION. 
(Mensteual  Insa^'itt.     Catamenial  Insanity). 

Inthemajority  of  women,  even  in  the  physiological 
condition,  the  return  of  the  menses  is  accompanied  on 
each  occasion,  with  intellectual  and  moral  disturb- 
ances, the  frequency  of  which  is  so  great  that  they 
have  ceased  to  attract  attention.  It  is  usually  more 
or  less  excitement,  a  tendency  to  loquacity,  to  dis- 
putation, to  susceptibility,  to  passion,  to  caprice; 
or,  on  the  other  hand,  a  depressed  condition  with  in- 
difference and  apathy  that  is  observed. 

In  certain  cases  these  alterations  of  character,  dis- 
position and  desires  of  women  may  reach  a  greater 
intensity  and  attain  the  proportions  of  insanity. 
The  alienation,  in  these  cases,  may  take  on  any  form 
whatever.  In  general  it  is  a  matter  of  a  transient 
attack  of  acute  melancholia,  or  more  often,  mania, 
lasting  only  through  the  period  with  which  it  is  con- 
nected and  ceasing  with  it,  essentially  ephemeral  and 
consequently  susceptible  of  being  classed,  strictly 
speaking,  in  the  transitory  and  periodic  insanities. 
"In  some  patients,"  says  M.  Ball,  "  the  religious 
ideas  predominate,  in  others  it  is  demonomania  that 
fills  the  scene.  Lastly,  there  are  women  who  have, 
at  each  appearance  of  the  menses,  an  attack  of 
nymphomania. " 

We  have  had  in  view,  so  far,  only  normal  men- 
struation in  the   description   of   these   phenomena. 


INSANITY  OF  MENSTEUATION.  339 

As  to  the  disorders  of  this  function,  and  notably  sup- 
pression of  the  menses  or  amenorrhoea,  and  dysmen- 
orrhoea,  their  action  on  the  mental  condition  is  still 
more  marked  and  frequent,  and  quite  frequently 
gives  rise  to  insanity.  Esquirol  made  them  out  to 
be  one-sixth  of  all  the  physical  causes  of  insanity  in 
women.  Every  one  knows  of  the  case  cited  by  that 
author,  of  a  young  girl  made  insane  on  account  of 
suppression  of  the  menses,  who,  on  rising  one  morn- 
ing threw  herself  on  her  mother's  neck,  crying  out 
that  she  w^as  cured,  her  menses  flowed  freely  and 
reason  was  immediately  re-established.  I  have 
many  times  seen  at  the  hospital  St.  Andre  at  Bord- 
eaux, in  the  service  of  Dr.  Lande,  a  young  hyster- 
ical female  who,  following  suppression  of  the  cata- 
menia,  had  every  month  a  palpebral  hamatidrosis, 
and  with  this  an  attack  of  acute  mania  lasting 
from  two  to  three  days,  with  daily  exacerbations  at 
a  fixed  hour.     In  the  interval  her  reason  was  perfect. 

The  psychic  disorder  frequently  reveals  itself  by 
irresistible  impulses,  by  a  tendency,  sometimes  peri- 
odic, to  dipsomania,  erotism,  theft,  arson,  homicide, 
and  especially  to  suicide. 

On  account  of  all  these  impulsions  that  may  occur, 
menstrual  insanity  raises  an  important  point  in  legal 
medicine.  We  should  also  never  lose  sight  of  this 
fact  while  the  question  arises  of  the  responsibility  of 
a  woman  guilty  of  a  misdemeanor  or  crime,  or  even 
of  any  very  extraordinary  behavior,  committed  at 
the  time  of  the  catamenia  or  during  the  suppression 
of  that  function, 


340    INSANITY  WITH  PHYSIOLOGICAL  CONDITIONS. 

In  a  general  way,  catamenial  insanity  is  almost 
always  judged  by  the  effects  of  the  return  of  the 
menstrual  flow,  and  when  that  appears  without  any 
improvement  of  the  mental  condition,  incurability  is 
to  be  feared.  In  the  great  majority  of  cases,  the 
return  of  the  periods  is  conseeuti\"^  to  mental  im- 
provement, leading  some  physicians  to  neglect  the 
function  and  treat  only  the  mental  disorder.  It  is 
better,  however,  in  princiiDle,  to  treat  the  cause,  that 
is,  the  menstrual  disorder.  It  is  rare  that  its  disap- 
pearance is  not  attended  with  a  general  check  in  the 
disease,  and  following  this  a  cure. 

§IV.  INSANITY  OF  PREGNANCY,  OF  PARTURI- 
TION. OF  THE  PUERPERAL  CONDITION  AND 
OF  LACTATION. 

(Puerperal  Insanity). 

We  designate  under  the  name  puerperal  insanity^ 
the  insanity  connected  with  the  various  periods  of 
pregnancy,  i.  e.,  gestation,  parturition,  the  puerperal 
condition  and  lactation. 

Puerperal  insanity  is  not  very  frequent  in  com- 
parison with  the  number  of  parturient  women.  Its 
principal  cause  is  heredity,  and  it  is  very  often  the 
case  that  the  daughters  of  insane  parents  become 
themselves  insane  on  the  occurrence  of  so  important 
an  event  as  pregnancy.  The  accessory  causes  are 
poverty,  debility  from  loss  of  blood  or  anaemia,  the 
mental  torment  and  anguish  due  to  a  false  step,  dif- 


PUEEPEEAL  INSANITY.  341 

ficult  labor,  supi^ression  of  the  lochia  or  the  niilk, 
and,  finally,  the  enfeeblement  from  a  prolonged  lac- 
tation. It  is  evident  that  former  attacks  of  insanity, 
whether  connected  with  pregnancy  or  not,  actively 
predispose  to  puerperal  insanity.  There  is  a  lack  of 
agreement  of  opinion  as  to  whether  or  not  primiparse 
are  more  exposed  than  multiparas,  and  vice  versa. 

As  regards  the  period  in  which  puerperal  insanity 
appears,  some  authorities  have  made  two  varieties: 
that  occurring  before  labor  {ante-partwm  insanity), 
and  that  occurring  after  labor  i^post-partura) . 
Others,  like  M.  Ball,  divide  pregnancy  into  four 
periods,  and,  therefore,  from  this  point  of  view  de- 
scribe four  varieties  of  puerperal  insanity. 

The  clinical  form  taken  by  puerperal  insanity  is 
always  mania  or  melancholia.  Most  frequently  it  is 
acute;  but  sometimes  it  is  manifested  in  a  hyper- 
acute form,  that  is  an  acute  delirium  in  the  maniacal 
form  and  stupor  in  the  melancholic  type. 

The  characters  of  the  mania  and  melancholia  con- 
nected with  the  puerperal  state  are  in  all  respects  the 
same  as  those  of  simple  mania  and  melancholia. 
Marce,  who  made  a  special  study  of  puerperal  insan- 
ity, says  that  it  differs  in  no  respect  in  its  symptoms 
from  ordinary  mania.  * '  I  have  proved  in  another 
work,"  says  he,  "  that  the  characters  assigned  to  it, 
such  as  the  peculiar  appearance,  the  odor  of  mice 
exhaled  by  the  patients,  are  due  solelj^  to  the  accom- 
panying puerperal  state,  and  the  erotic  manifestations 
in  this  morbid   condition  are  far  from  having  the 


342   rS-SANITY  WITH  PHYSIOLOGICAL  CONDITIONS. 

value  and  frequency  assigned  them  by  some  author- 
ities." 

There  is  no  necessity,  therefore,  of  describing 
puerperal  mania  and  melancholia  in  detail.  It  will 
suffice  to  point  out  at  each  stage  of  the  physiological 
process  the  forms  of  generalized  insanity  that  may 
occur,  and  the  more  or  less  striking  peculiarities 
they  may  borrow  from  the  coexistence  of  this  pro- 
cess. 

1.  Pkegnancy. — A  great  many  women  present 
more  or  less  marked  intellectual  and  moral  disturb- 
ances during  pregnancy  without  actually  becoming 
insane.  It  is  hardly  necessary  to  mention  the  long- 
ings, the  extravagant  desires,  the  depravations  of  the 
api^etite  (pica  and  malacia),  and  also  sometimes  the 
tendency  to  theft,  which  are  sometimes  observed  in 
the  pregnant  female. 

The  insanity  of  pregnancy,  properly  so-called,  gen- 
erally makes  its  appearance  during  the  last  three 
months,  and  habitually  takes  the  melancholic  form, 
especially  the  subacute  (melancholic  depression)  or 
acute  form.  Sometimes  it  ends  at  the  time  of  labor, 
but  more  often  it  continues  during  the  puerperal 
period. 

2.  Labor. — Childbed  insanity  or  that  which 
begins  at  the  moment  of  labor  is  rather  rare.  Apart 
from  heredity,  it  has  for  its  causes,  either  a  difficult 
delivery,  or  the  torments  of  a  clandestine  birth,  or 
eclamptic  complications,  and  consists  in  a  temporary 


PUEEPEEAL  INSANITY. 


343 


transient  delirium,  generally  of  the  maniacal  type, 
with  sudden  impulses,  and  especially  with  a  tendency 
to  infanticide.  Some  cases  have  been  reported  in 
which  each  uterine  contraction  was  accompanied,  in- 
stead of  a  pain,  with  a  sudden  spell  of  excitement 
that  ceased  whenever  the  pain  was  over.  Such  cases 
are  infrequent. 

3.  PuEEPEEAL  CoNDiTioisr. — Insanity  connected 
with  the  puerperal  state,  or  puerperal  insanity,  prop- 
erly so-called,  is  that  which  appears  after  delivery  and 
before  the  return  of  menstruation,  especially  about 
the  fifth  or  sixth  day.  It  is,  with  the  insanity  of  lac- 
tation, the  most  frequent  of  all. 

It  is  usually  preceded  by  prodromata,  such  as  ir- 
ritability, general  tnalaise^  excessive  anxiety,  and 
when  the  attack  occurs  it  takes,  three  times  out  of 
four,  the  form  of  mania,  and  chiefly  the  acute  type. 

It  has  been  claimed  that  erotic  tendencies  and 
obscenity  are  more  marked  in  puerperal  mania  than 
in  any  other  form.  We  have  seen,  with  Marce,  what 
should  be  thought  of  this  peculiarity,  which  is  really 
only  a  shade  of  difference  not  easily  determined. 

A  symptom  that  seems  more  reliable,  is  the  fre- 
quency, in  puerperal  insanity  whether  of  the  maniacal 
or  melancholic  form,  of  the  perversion  of  the  affective 
sentiments,  and  especially  the  excessive  morbid  aver- 
sion of  the  patient  to  her  husband  and  children. 

Puerperal  melancholia  takes  also  the  acute  or  even 
the  hyperacute,  that  is,  the  stuporous  form.     Apart 


344   IXSAN^ITT  WITH  PHYSIOLOGICAL  CONDITIONS. 

from  perversion  of  the  affective  sentiments  and  pos- 
sibly a  more  decidedly  suicidal  tendency  it  has  no 
characters  peculiar  to  itself. 

4.  Lactation. — Insanity  connected  with  lacta- 
tion manifests  itself  in  general  towards  the  second  or 
third  month  of  nursing.  It  has  for  its  chief  causes, 
aniemia,  poverty,  and  above  all,  the  debility  due  to 
lactation.  It  affects  by  preference,  the  types  of  acute 
or  subacute  melancholia  (melancholic  depression). 

Prognosis. — In  a  general  way,  puerperal  insanity 
is  rather  curable,  especially  a  first  attack,  but  less  so , 
nevertheless,  than  simple  generalized  insanity.  That 
occurring  during  gestation  or  during  labor  is  the 
most  curable ;  that  occurring  during  lactation  is,  on 
the  other  hand,  more  serious  in  its  prognosis.  It 
may  also  be  said  that  the  maniacal  form  of  puerperal 
insanity  offers  the  best  chances  for  cure. 

There  is  no  form  more  subject  to  relapses  than  puer- 
peral insanity,  and  a  first  attack  predisposes  almost 
inevitably  to  a  second.  Thus  there  are  women  who 
have  an  attack  with  each  pregnancy,  sometimes  of 
the  maniacal,  sometimes  the  melancholic  form.  At 
each  attack  the  prognosis  becomes  more  grave,  and 
it  is  rare  that  after  a  second  or  third  attack  the  dis- 
ease does  not  pass  into  the  chronic  condition. 

The  treatment  is  the  same  as  that  ordinarily  em- 
ployed in  simple  mania  and  melancholia,  with  such 
special  indications  as  are  required  by  the  condition 
of  the  woman,  the  anaemia,  the  suppression  of  the 
milk,  the  return  of  the  catamenia,  etc. ,  etc. 


INSANITY  OF  THE  MENOPAUSE.  345 

§V.     INSANITY   OF  THE  :MEN0PAUSE. 
(Climacteric  Insanity). 

The  menopause,  so  justly  called  a  critical  epoch,  is 
a  dangerous  period  for  many  women  to  traverse,  and  is 
very  frequently  the  occasion  of  intellectual  and  moral 
perturbations,  and  psychic  modifications,  which  may 
sometimes  go  so  far  as  to  cause  insanity.  NTervous 
women  especially,  and  such  as  are  predisposed  to  men- 
tal disease,  incur  the  danger  of  losing  their  reason  at 
this  period.  It  is  not  an  infrequent  thing  to  see 
those  who  are  thus  originally  predisposed,  but  who 
have  been  able  to  keep  this  tendency  latent  during 
all  their  active  life,  in  spite  of  all  the  physical  and 
moral  shocks  they  have  endured,  become  suddenly 
insane  at  this  time  from  the  sole  influence  of  the 
physiological  suppression  of  the  menses.  In  others 
who  have  already  had  one  or  two  attacks  of  insanity, 
the  change  of  life  is  the  occasion  of  a  new  attack  or 
relapse.  This  possibility  is  especially  to  be  dreaded 
for  women  whose  first  attacks  of  insanity  were  con- 
nected with  either  puberty,  menstrual  disorders,  or 
pregnancy,  in  a  word,  with  any  one  of  the  great  pro- 
cesses of  sexual  life,  the  influence  of  which  we  are 
studying.  For  them,  more  than  others,  is  the  last  step 
of  this  sexual  existence  a  difiicult  one. 

Like  the  insanity  of  puberty  and  menstrual  in- 
sanity, the  insanity  of  the  menopause  does  not,  to 
tell  the  truth,  present  any  special  clinical  physiog- 
nomy, and  the  symptoms  may  be  infinitely  varied ; 
nevertheless,  here  also  it  is  in  the  impulsive  sphere 

Ment.  Med.— 22. 


346    ESrSAHTTT  WITH  PHTSIOLOGICAL  CONDITIONS. 

that  the  greatest  disturbances  make  their  appearance, 
and  the  tendency  to  dipsomania,  to  theft,  to  homi- 
cide, to  arson,  but  still  more  to  suicide,  forms  the 
prominent  feature  of  this  disorder  which  is,  as  a  rule, 
melancholic  in  its  type.  The  delusions  often  assume 
the  erotic  or  mystic  type  or  are  those  of  persecution, 
and  they  are,  in  many  cases,  accompanied  with 
bizarre  sexual  hallucinations,  such  as  were  described 
in  the  remarks  on  these  symptoms. 

TJie  critical  age,  which  seems  to  exert  so  active 
an  influence  on  the  development  of  insanity,  some- 
times, in  certain  more  or  less  chronic  cases,  plays  the 
part  of  a  crisis.  At  this  time,  it  may  be  said,  their 
future  is  decided  for  good,  when  there  yet  remain 
any  chances  of  reason  being  restored ;  that  age  once 
passed  they  either  recover  and  are  thereafter  protected 
from  attacks  of  insanity,  or  they  are  sunk  irrevoca- 
bly into  incurability  and  dementia. 

Insanity  of  the  change  of  life  is  peculiar,  so  to 
speak,  to  the  female  sex.  Nevertheless  men  appear 
to  be  sometimes  subject  to  it,  since,  according  to  some 
authorities,  they  have  also  their  great  climacteric 
between  the  ages  of  fifty  and  sixty.  In  them,  even 
more  prominently  than  in  women,  the  symptoms  of 
the  disorder  consist  chiefly  in  a  state  of  constant 
dread  of  some  misfortune,  the  fear  of  damnation  and 
tendency  to  suicide,  i.  e.,  in  melancholia  of  the 
anxious  type. 

Insanity  of  the  menopause  is  generally  curable 
and  its  duration  is  ordinarily  limited  to  that  of  the 


INSANITY  OF  THE  MENOPAUSE.  347 

critical  period.  We  can  only  call  to  mind  excep- 
tional instances  where  the  insanity  came  on  only  after 
the  menopause  and  then  manifested  itself  by  periodic 
attacks  occurring  at  the  epochs  of  the  former  mens- 
trual periods. 

The  treatment  of  climacteric  insanity  is  often  very 
difficult,  as  there  is  no  absolute  line  of  conduct  here 
to  be  followed,  as  in  cases  where  the  mental  disease 
is  due  to  amenorrhoea.  The  chief  indication,  apart 
from  hygienic  and  moral  treatment  which  must  never 
be  neglected,  is  to  direct  the  efforts  against  the  nerv- 
ous disturbances,  the  vaso-motor  disorders  and  the 
accompanying  anaemia.  Tonics,  and  external  modi- 
fying agencies  (baths,  douches,  massage,  electricity) 
are  the  remedies  best  adapted  to  this  end. 


Cbapter  f  ♦ 

msANITY    CONNECTED    WITH    LOCAL 
VISCERAL   DISEASE. 

(Sympathetic  Insanity). 


§1.     IXSA^^ITY   DUE    TO  DISEASE   OF   THE    GEN- 
ITAL AND  GENITO-UIUNARY  ORGANS. 

A. — Affections  of  the  Uterus  and  its  Appendages. 

( Uiero-  Ovarian  Insanity). 

If  the  physiological  processes  that  have  their  point 
of  departure  in  the  generative  organs,  are  often  the 
causes  of  mental  trouble,  this  is  perhaps  still  more  fre- 
quentl}''  the  case  with  their  diseases.  On  account  of 
the  direct  connections  that  unite  the  sexual  to  the 
cerebral  life,  there  is  not  a  single  affection  of  the 
genito-urinary  apparatus  that  may  not  in  time  affect 
the  brain  and  cause  mental  disorder. 

Thus  in  the  male  we  often  see  onanism,  seminal 
losses,  and  disease  of  the  urethra,  especially  blen- 
norrhagia  and  blennorrhoea,  affect  the  mind,  depress 
the  spirits,  and  gradually  produce,  either  hypochon- 
dria or  neurasthenia,  or  even  a  delusional  melancholia 
Avith  suicidal  tendency.  Nevertheless,  mental  disor- 
ders due  to  the  affections  of  the  sexual  organs  are 
comparatively  rare  in  the  male,  while,  on  the  con- 
trary, they  are  quite  common  in  the  female  sex. 


DISEASES  OF  THE  GENITO-UKINART  SYSTEM.      349 

The  majority  of  women  suffering  from  organic 
disease  of  the  uterus,  fall  gradually,  in  fact,  into 
depression,  moroseness,  and  hysteria;  they  change 
in  their  characters,  and  become  irritable  to  excess, 
sometimes  even  passionate  and  violent;  occasionally, 
indeed,  they  go  a  degree  farther  and  pass  fully  into 
the  domain  of  insanity.  According  to  general 
opinion  of  observers  the  form  taken  by  the  mental 
disease  in  these  cases  is  most  frequently  melancholia 
with  a  tendency  to  suicide. 

It  is  in  this  variety  of  alienation  especially  that 
we  find,  together  with  more  or  less  pronounced  erotic 
and  mystical  notions,  those  queer  hallucinations  of 
the  genital  sense,  in  which  the  patients  experience 
extraordinary  sensations  of  a  painfully  pleasurable 
kind,  and  which  give  a  special  character  to  their  de- 
lusions. These  are  the  lunatics  that  make  charges 
of  dishonorable  liberties  attempted,  of  their  having 
to  undergo  disgusting  tests,  that  all  kinds  of  objects 
are  introduced  into  their  parts,  that  they  are  outraged 
and  made  to  experience  the  feelings  of  coition  at 
night,  that  they  are  pregnant  and  can  feel  the  motion 
of  the  infant,  that  they  have  animals  in  their  bellies, 
that  they  are  about  to  be  confined,  etc.,  etc.  Some 
of  these  also,  in  order  to  combat  with  all  their  might 
these  imaginary  outrages,  devise  very  extraordinary 
methods  of  self -protection,  they  fasten  their  thighs 
together  at  night,  they  tampon  the  vulva  with  old  rags 
or  towels,  and  even  introduce  foreign  substances 
deeply  in  the  vagina.     Sometimes  it  is  their  own 


350      IXSAXITY  WITH  LOCAL  VISCERAL  DISEASE. 

account  of  their  sensations -that  attracts  attention  to 
the  condition  of  their  organs,  and  thus  reveals  the 
true  cause  of  the  mental  disorder,  by  the  discovery 
of  some  of  their  existing  morbid  conditions. 

Most  uterine  affections  are  capable  of  engendering 
mental  disease,  by  sympathy,  and  it  does  not  appear 
that  out  of  the  whole  number,  any  one  has  any 
special  influence  more  than  the  others  in  this  regard. 

Dr.  Wiglesworth  (1885),  who  made  one  hundred 
and  nine  autopsies  of  insane  women  with  particular 
reference  to  this  point,  has  obtained  the  following  re- 
sults :  in  forty-two  the  sexual  organs  Avere  healthy  or 
without  any  appreciable  lesion ;  in  sixty-seven  there 
were  found  more  or  less  serious  alterations.  In 
twenty-two  cases  the  disease  seemed  to  have  no  partic- 
cular  con  nection  with  the  insanity.  In  the  other  f orty- 
five  there  was  one  case  of  absence  of  the  uterus ;  four 
cases  of  conical  cervix  with  pinhole  os ;  four  cases  of 
retroversion ;  five  of  retroflexion ;  and  one  of  retro- 
flexion and  retroversion  combined;  one  case  of  pro- 
lapsus; six  of  increased  volume  of  uterus;  six  of 
fibroma ;  six  of  chronic  peritonitis ;  one  case  of  hyper- 
trophy with  induration  of  the  lips  of  the  cervix ;  one 
case  of  uterine  cancer;  nine  cases  of  diseased  ovaries 
and  tubes.  Fibroid  tumors  and  displacements  of  the 
womb,  together  with  alterations  of  the  ovaries  or 
their  total  ablation,  seem  therefore  to  be  the  lesions 
that  have  most  influence  on  mental  disorders.  Sim- 
ple ulcerations  or  granulations  of  the  cervix  with 
or  without  leucorrhoea,  however,  are  suflicient  to 
causa  these  same  disorders. 


DISEASES  OP  THE  GENITO-rEINARY  SYSTEM.     351 

Very  often,  and  I  may  say  generally,  the  psychic 
disorders  follow  exactly  the  phases  of  the  utero- 
ovarian  symptoms,  increasing  with  them  or,  on  the 
other  hand,  improving  and  disappearing  as  the  latter 
improve  and  disappear.  There  have  even  been  cases 
reported  of  the  disappearance  of  insanity  in  cases  of 
prolapsus,  as  soon  as  the  uterus  was  replaced  with 
a  pessary.  These  facts,  which  are  very  curious, 
establish  firmly  the  relation  existing  between  the 
mental  trouble  and  the  uterine  lesion,  and  the  sub- 
ordination of  the  course  of  the  former  to  the  pro- 
cesses of  the  latter. 

Nevertheless,  this  is  not  always  the  case,  and  we 
may  see  either  the  uterine  lesion  disappear  and  the 
mental  disorder  persist,  or  rather  the  intellectual 
trouble  disappearing  while  the  uterine  affection  is 
stationary. 

It  is  none  the  less  true  that  we  should  never  lose 
sight  of  the  frequency  of  this  sympathetic  relation, 
and  should  give  attention  to  the  condition  of  the 
generative  organs,  not,  perhaps  as,  Azani  counsels, 
in  all  cases  of  suicidal  melancholia,  but  at  least  in 
such  patients  as  have  delusions  relating  to  these 
organs  or  the  strange  sexual  hallucinations  which 
have  been  mentioned  in  the  preceding  pages. 

B. — Diseases  of  the  Kidneys  and  Bladder. 
{Brightic  Insanity). 

The  relations  of  insanity  with  kidney  disorders 
have   been   long    since    observed,    particularly   by 


352       INSAiHTT  WITH  LOCAL  VISCERAL  DISEASE. 

Lasegue,  Koppen,  Raymond,  Pierret,  and  Bouvat. 
It  is,  lioweA'er,  of  late  years  that  attention  has  been 
given  to  this  question  by  several  French  physicians 
who  have  discussed  it  in  the  Societe  medicale  des 
hopitaux,  and  have  recognized,  with  Dieulafoy,  a 
Brightic  insanity.  Unfortunately  there  have  been 
confounded,  rather  carelessly,  all  the  psychopathic 
conditions  susceptible  of  coexisting  with  albuminuria, 
whatever  may  be  their  form  or  origin.  A  foreign 
alienist,  Madame  Alice  Bennett,  has  recently  made 
uraemic  poisoning  one  of  the  most  frequent  causes 
of  mental  alienation,  and  as  the  starting  point  of 
nearly  all  cases  of  melancholia  (American  Journal 
OF  Insanity,  October,  1890).  There  is  in  this  an 
evident  exaggeration,  against  which  it  is  important 
to  protest.  This  is  what  M.  JofProy  has  attempted 
in  an  interesting  clinical  lecture  which  gives  correct- 
ly, from  this  point  of  view,  the  actual  state  of  our 
knowledge  of  the  subject.  {Bulletin  Medical^ 
February,  1891). 

According  to  M.  Joffroy,  a  capital  distinction 
must  first  be  made  between  the  nervous  accidents  of 
acute  delirious  uraemia  and  Brio-htic  or  uraemic  in- 
sanity. 

The  first  of  these  is  an  acute  and  transient  delirium, 
or  to  express  it  more  correctl}'',  a  non-vesanic  febrile 
delirium  occurring  under  the  influence  of  an  infec- 
tious disorder  accompanied  by  nephritis  and  fever. 

Briglitic  insanity  comprises  the  cases  in  which  the 
existing  albuminuria  is  responsible  alone  for  the  in- 


DISEASES  OP  THE  GENITO-URINARY  SYSTEM.     353 

sanity,  and  those  where,  by  arousmg  a  vesanic 
predisposition,  it  simply  brings  into  activity  a  latent 
mental  disorder.  There  are,  consequently,  two 
species  of  albuminuric  insanity. 

In  the  first,  albuminuria  occurs  in  a  person  with 
no  antecedents  of  mental  disease,  either  personal  or 
hereditary,  but  presenting  a  neuropathic  predispo- 
sition. Under  its  influence  the  brain  suffers  in  a 
special  way  from  the  uraemic  intoxication ;  nutrition  is 
vitiated  and  insufficient,  and  a  quiet,  mild  delirium, 
very  closely  allied  to  dementia,  may  appear,  continue 
as  long  as  the  albuminuria,  increase  or  diminish  with 
it,  and  even  disappear  if  the  patient  recovers  from 
the  bodily  disorder. 

In  other  cases,  always  appertaining  to  the  same 
species,  vascular  lesions  occur  under  the  influence  of 
the  albuminuria,  such  as  hsemorrhagic  or  necrobiotic 
lesions  of  the  brain,  and  the  dementia  thus  due  to  a 
profound  organic  alteration  may  still  be  aggravated 
with  the  fluctuations  of  the  albuminuria,  but  it  can- 
not recover  when  that  disappears. 

According  to  M.  Joffroy,  there  is  a  true  Brightic 
insanity  developed,  not  because  of  a  vesanic  predis- 
position, but  by  the  long  continued  albuminuric  in- 
toxication disturbing  the  nutrition  of  the  nervous 
centres  or  even  producing  in  them  organic  lesions. 
These  cases,  however,  are  rare,  and  the  insanity  is  of 
an  inactive  type,  dementia  predominating. 

In  the  second  variety,  we  see  a  true  insanity  super- 
vene in  the  course  of  an  albuminuria,  due  mainly  to 


354      rN-SAIHTY  WITH  LOCAL  VISCERAL  DISEASE. 

a  hereditary  vesanic  taint,  and  only  albuminuric  in 
that  the  kidney  disorder  is  its  exciting  cause.  It  is 
not  albuminuric  insanity  but  insanity  aroused  by 
albuminuria.  It  may  therefore  take  very  different 
forms.  Some  patients  have  hallucinations  of  sight 
and  hearing,  others  ideas  of  persecution  and  erotic 
ideas,  or  religious  delusions ;  still  others  are  maniacal, 
melancholic  or  suffer  iYova.folie  du  doute,  etc. 

The  distinction  between  these  various  conditions 
is  important  in  view  of  tbe  prognosis.  In  acute 
delirious  urasmia,  the  mental  symptoms  generally 
subside  after  a  little  time,  and  there  is  no  necessity 
of  sequestrating  the  patient. 

In  the  first  variety  of  Brightic  insanity,  that 
which  is  due  directly  to  the  intoxication,  we  ought 
not  to  advise  asylum  treatment,  unless  very  guard- 
edly; the  insanity,  not  of  a  dangerous  type,  follow- 
ing closely  the  course  of  the  albuminuria,  may 
improve  as  it  improves,  and  sometimes  disappear,  in 
case  there  are  no  profound  organic  cerebral  lesions. 

In  the  second  variety,  that  where  the  albuminuria 
is  only  the  exciting  cause,  there  is  usually  no  partic- 
ularly close  connection  between  the  evolution  of  the 
l^sychic  symptoms  and  the  renal  disease.  This  in- 
sanity is,  therefore,  susceptible  to  the  usual  means  of 
treatment,  especially  isolation. 

It  goes  without  saying  that  in  all  cases,  of  what- 
ever kind,  milk  diet  used  judiciously,  forms  an 
important  part  of  the  treatment. 

Like  renal  diseases,  disorders  of  the  bladder  and 


DISOEDERS  OF  DIGESTIVE  TEACT,  ETC.  355 

the  urinary  ducts  seem  to  have  a  real  influence  on 
the  development  of  insanity.  It  seems  established 
that  persons  affected  with  lithiasis  and  particularly 
with  cystitis  and  retention  of  urine,  are  for  the  most 
part  melancholic,  depressed  and  liypochondriacal, 
passive  and  easily  discouraged  and  sometimes  even 
driven  to  suicide.  It  is,  in  fact,  well  established 
that  the  urinary  function  is  very  often  the  starting 
point  of  morbid  mental  preoccupation,  and  that 
chronic  lesions  of  its  organs  of  excretion,  frequently 
engender  a  more  or  less  profound  condition  of  sad- 
ness, which  may,  after  a  time,  end  in  insanity  prop- 
erly so  called. 

§  II.  mSANITY  CONNECTED  WITH  DISORDERS  OF 
THE  DIGESTIVE  TRACTS,  AVITH  DISEASE  OF 
THE  LIVER  AND  WITH  INTESTINAL  PAR- 
ASITES. 

A. — Diseases  of  the  Digestive  Tracts. 

Direct  relations  exist  between  the  mental  condition 
and  that  of  the  digestive  functions.  When  the 
latter  are  in  any  way  disordered,  it  is  rare,  in  case 
the  trouble  persists,  that  it  is  not  followed  by  a  more 
or  less  profound  involvement  of  the  intellect  and 
emotions. 

Simple  constipation,  angina,  and  gastric  uneasi- 
ness are  enough  at  times  to  cause  depression,  sad- 
ness, melancholia  with  refusal  of  food,  hallucinations 
of  taste,  delusions  and  insanity. 

Diseases  of  the  intestines  have  also  a  very  powerful 


356       IN-SANITT  WITH  LOCAL  VISCERAL  DISEASE. 

action  on  the  development  of  mental  alienation. 
Esqnirol,  it  is  well  known,  affirmed  that  melancholia 
was  due  to  a  displacement  of  the  transverse  colon. 
Wichmann,  Hesselbach  and  Greding  have  also  made 
the  same  observation.  Bayle  has  also  shown  in  his 
thesis  that  enteritis  and  gastro-enteritis  may  produce 
sympathetically  cerebral  disorders.  Lastlj^  Dr.  Holt- 
hof  has  shown  that  duodenal  catarrh,  especially  after 
it  has  passed  into  the  chronic  condition,  gives  rise  to 
a  marked  state  of  depression  in  the  subjects;  but  in 
individuals  already  predisposed  to  neuroses,  it  may 
become  the  source  of  more  serious  mental  disorder. 
In  nearly  every  case  the  symptoms  are  those  of 
hypochondria ;  at  other  times  it  develops  into  a  reg- 
ular melancholia,  with  ideas  of  persecution,  of  unwor- 
thiness,  with  morbid  exaggeration  of  conscientious- 
ness, etc. ,  etc. ,  or  else  the  patients  become  unquiet, 
fretful,  quarrelsome  and  excessively  irritable. 

Alterations  of  the  peritoneum  and  its  folds,  the 
mesentery  and  the  epiploons,  may  also  give  rise  to 
mental  troubles. 

The  majority  of  the  gastro-intestinal  aifections, 
innocent  as  they  may  be  in  appearance,  are  therefore 
liable  to  engender  mental  alienation.  But  of  all  those 
that  can  thus  react  on  the  intelligence,  the  most  im- 
portant with  the  exception  of  cancer  which  is  a  gen- 
eralized disease,  is  certainly  dyspepsia,  which  takes 
in  this  regard  the  foremost  place. 

All  or  nearly  all  of  the  dyspeptics  present  in  some 
degree,  either  nervous  disturbances  (gastro-intestinal 


DISORDERS  OF  DIGESTIVE  TRACT,  ETC.  357 

neurasthenia),  or  mental  disturbances,  such  as 
eccentricities  of  character,  attacks  of  depression, 
marked  tendency  to  irritability,  and  attacks  of  tem- 
per, and  a  propensity,  often  irresistible,  to  suicide 
and  to  diiDsomania.  It  is  not  uncommon  to  see  dys- 
pepsia bring  on  mental  alienation,  and  it  is  especially 
in  these  cases  that  the  chronic  gastric  disorders 
improve  with  the  appearance  of  the  insanity,  to 
reappear  when  it,  in  its  turn,  has  passed  away. 

It  should  be  added,  for  the  sake  of  completeness, 
that  the  dyspeptic  troubles,  whether  they  are  the 
actual  cause  of  the  insanity,  or  occur  in  persons 
already  insane,  usually  give  rise  to  two  mental 
s^^mptoms  that  are  almost  characteristic.  These 
symptoms  are :  (1)  the  refusal  of  food,  so  intimately 
connected  with  dys^iepsia,  which  is  not  a  mere 
sitiophobia  not  connected  in  any  degree  whatever 
with  gastric  disorders.  The  second  symptom 
consists  in  the  almost  constant  existence  of  these 
disorders  of  the  sensibility  which  have  been  called 
internal  hallucinations  and  illusions,  and  which  lead 
the  patients  to  believe  that  their  stomachs  and 
abdomens  are  the  seat  of  extraordinaiy  diseases,  that 
they  have  been  poisoned,  that  their  food  smells  of 
phosphorus  and  arsenic,  that  thej  have  living  animals 
in  their  abdomens,  that  they  smell  badly,  that  they 
are  rotten,  etc.,  etc.  The  usual  result  of  this  mental 
condition  is  a  suicidal  tendency,  which  is,  in  fact, 
quite  marked  in  insanity  of  gastric  origin. 

The  prognosis  of  the  mental  disease  in  all  these 


358       INSAiaTT  TTITH  LOCAL  VISCERAL  DISEASE. 

cases  is  entirely  dependent  on  the  nature  and  tlie  sever- 
ity of  the  organic  disease  that  gave  rise  to  it.  It 
is  therefore  only  really  serious  in  those  which  are  in 
their  nature  but  slightly  susceptible  of  cure.  The 
other  symptomatic  disorders  yield  readily,  and  the 
cases  of  refusal  of  food,  spoken  of  above,  under  the 
influence  of  medication,  cause  the  disappearance  of 
the  visceral  trouble  itself, 

B. — Diseases  of  the  Ln^ii  and  Biliary  Ducts. 
{Hepatic  Insanity). 

Affections  of  the  liver  and  its  annexes  play  a 
rather  important  part  in  the  production  of  sympa- 
thetic insanity ;  their  action  has  been  admitted  from 
all  time,  and  the  ancient  theory  that  made  the  liver 
the  exclusive  starting  point  of  melancholia,  is,  at 
bottom,  only  the  exaggeration  of  the  actual  influ- 
ence of  tliat  organ  on  the  mind.  Still  in  our  time 
some  authors,  Burrows  and  Hammond  among  tbem, 
assign  to  hepatic  disorders  one  of  the  first  places  in 
the  development  of  mental  alienation. 

Among  the  affections  of  the  liver  that  appear  to 
really  influence  the  mental  condition,  h^^pertrophy 
and  especially  abscess  appear  in  the  first  rank. 

Without  c^oinc:  so  far  as  Professor  Hammond  who 
attributes  nearly  all  cases  of  hypochondria  and  mel- 
ancholia to  abscess  of  the  liver,  it  ought  to  be  recog- 
nized that  the  affections  of  this  organ  may  become 
under  certain  conditions  the  starting  point  of  mental 


DISOEDEKS  OF  DIGESTIVE  TRACT,  ETC.  359 

disturbances  that  usually  take  the  characters  of  mel- 
ancholia and  hypochondria. 

Besides  hypertrophy  and  abscess,  the  principal  les- 
ions of  the  liver  that  have  been  noticed  in  the  insane 
are  tubercles  of  various  sizes  disseminated  in  the  par- 
enchyma of  the  gland,  fatty  degeneration,  hydatid 
cysts,  adhesions  to  the  diaphragm,  and  finally  vic- 
ious conformation  and  abnormal  situation  of  the 
organ. 

The  organic  affections  of  the  gall-bladder  and 
biliary  ducts  act  probably  in  the  same  manner  as  the 
lesions  of  the  liver  itself.  In  some  cases  there  have 
been  found  obstructions  of  the  duct,  in  others  the 
gall-bladder  was  atrophied  and  filled  with  a  slightly 
viscous  and  almost  colorless  liquid. 

Hepatic  calculi  are  extremely  common  in  the  in- 
sane, especially  in  melancholiacs  and  hypochondriacs, 
and  there  is  no  observer  who  has  not  found  them  at 
the  autopsies  of  these  patients,  often  in  considerable 
number  and  of  a  size  that  surprises  one  at  their  slight 
eifect  during  life. 

C. — Helminthiasis  (Intestinal  Worms), 
( Verminous  Insanity). 

Although  worms,  the  presence  of  which  is  rather 
often  evidenced  by  A^arious  nervous  symptoms,  may 
locate  themselves  in  any  portion  of  the  body,  the 
l^sychic  phenomena  they  produce  seem  to  find  their 
natural  place  among  the  sympathetic  insanities  con- 
nected with  lesions  of   the   abdominal    orcfans,  on 


360      LN^SANITY  "WITH  LOCAL  VISCERAL  DISEASE. 

account  of  the  marked  predilection  of  these  entozoa 
for  those  organs,  and  also  on  account  of  their  more 
decided  action  on  the  state  of  the  intelligence  when 
they  occupy  the  intestine.  Moreover,  the  presence  of 
worms  in  the  different  portions  of  the  digestive  tracts 
is  generally  associated  with  more  or  less  alteration  of 
these  parts,  which  aids  in  their  action  on  the  develop- 
ment of  insanity. 

It  was  in  the  beginning  of  the  present  century 
that  certain  authors,  imbued  with  the  ideas  of  Pinel 
on  insanity  by  consensus^  began  to  attribute  some 
importance  to  intestinal  worms  as  a  factor  in  the 
production  of  mental  disease.  Prost,  in  his  "  Coup 
d^oeil  jyliysiologiqne  sur  la  folie^''''  warmly  upheld 
their  imjDortance  and,  like  all  advocates  of  new  views, 
carrying  things  to  extremes,  he  made  insanity  depend 
in  the  majority  of  cases  on  the  presence  of  intestinal 
parasites.  Generalizing  on  the  facts  he  had  observed, 
and  making  them  serve  for  the  erection  of  a  com- 
plete theory,  Prost  held  that  very  often  the  humors, 
and  particularly  the  bile,  became  altered,  and  that 
it  was  in  the  bile,  thus  changed,  that  the  worms 
originated  whose  presence  ultimately  gave  rise  to 
the  troubles  of  the  intelligence.  This  subordination 
of  the  origin  of  the  parasites  to  a  morbid  condition 
of  the  abdominal  organs,  approached  closely,  as  we 
see,  to  the  theory  of  the  origin  of  insanity  by  alter- 
ations of  the  liver  or  digestive  tracts. 

Prost's  ideas,  too  exclusive  as  they  were,  were  not 
accepted,  even  in  his  own  times,  without  some  reser- 


DISORDEKS  OF  DIGESTIVE  TRACT,  ETC.  361 

vations.  Since  then  attention  has  been  repeatedly 
drawn  to  the  subject ;  some  cases  have  been  published, 
and  it  is  generally  admitted  at  the  present  time  that 
intestinal  worms  may,  under  certain  circumstances, 
develop  insanity  by  sympathetic  reaction. 

Dr.  Vix,  who  has  made  a  special  study  of  helmin- 
thiasis in  the  insane,  has  ascertained  that  convulsive 
nervous  affections,  eclampsia,  hysteria,  etc. ,  are,  of  all 
nervous  disorders,  the  most  common  with  these  par- 
asites. When  a  mental  disorder  is  produced  it  is  gen- 
erally hypochondria  or  mania.  According  to  the 
same  authority,  certain  mental  dispositions  and  impul- 
sions are  peculiar  to  insanity  connected  with  hel- 
minthiasis, and  these  will  vary  according  to  the 
locality  of  the  parasite,  the  reflex  action  on  the 
brain  changing,  in  fact,  according  to  the  region 
of  the  body  infested.  Thus  in  the  insane  who  ex- 
hibit these  psychic  peculiarities,  eight  out  of  every 
hundred  are  troubled,  according  to  Vix,  with  worms, 
and  among  the  others  we  do  not  find  marked  animal 
instincts  or  the  tendency  to  skatophagy,  i.  e.,  eating 
excrement  and  filth,  which  would  appear  to  indicate 
that  these  symptoms  are  more  common  in  mental 
disease  connected  with  helminthiasis. 

Some  disturbance  of  the  sensibility  is  commonly 
met  with  in  these  cases,  especially  hypersesthesia, 
and  in  some  instances  various  perversions  of  the  gus- 
tatory sense.  Genital  excitement  is  also  frequent, 
also  hemeralopia  which  seems  to  be  specially  con- 
nected with  the  presence  of  oxyii^ms. 

Ment.  Med.— 23. 


362       rN'SAIOTY  WITH  LOCAL  VISCERAL  DISEASE. 

HelmiDthiasis  is  also  sometimes  accompanied  with 
nervous  symptoms  or  such  general  phenomena  as 
convulsions,  pupillary  dilatation,  palpitations,  tin- 
nitus, weakness  of  the  limbs,  cachectic  jDallor,  etc. 
Moreover,  (always  according  to  Dr.  Vix),  it  is  more 
frequently  followed  by  insanity  in  the  female  than  in 
the  male  sex.  Finally,  in  the  former,  trichocephalus 
is  most  common,  in  the  latter  oxyurus. 

Verminous  insanity  is  not  commonly  obstinate, 
and  yields  readily  to  antihelminthics.  Some  worms, 
nevertheless,  are  very  difficult  to  get  rid  of,  and 
have,  moreover,  a  tendency  to  recur,  which  compli- 
cates the  prognosis  to  a  certain  extent  and  makes 
relapses  possible. 

§ni.     DISEASES   OF  THE  CIRCULATORY 
APPARATUS. 

A. — Diseases  of  the  Heart. 

{Cardiac  Insanity). 

Affections  of  the  heart  have,  rather  frequently,  an 
injurious  effect  on  the  mind  and  are  capable  of  pro- 
ducing various  disorders  of  the  ideas  and  the 
emotions,  from  simple  change  of  character  and  rudi- 
mentary morbid  conc;eptions  to  confirmed  insanity. 

The  so-called  cardiac  insanity  is  not,  properly 
speaking,  a  sympathetic  insanity,  certainly  not  if  we 
hold  strictly  to  the  signification  of  the  term  sympa- 
thetic. Nevertheless,  since  it  is  hardly  possible  to 
point  out  exactly  what  cerebral  circulatory  disorders 


DISEASES  OP  THE  CIRCULATORY  APPARATUS.    363 

are  produced  in  cardiac  disease,  and  since,  on  the 
other  hand,  the  disorders  of  the  circulation  that  are 
constant  as  symptoms  of  the  heart  lesions  are  far 
from  causing  delusional  or  vesanic  symptoms  in  all 
cases,  we  must  recognize  that  the  nervous  system  is 
a  potent  agent,  if  not  the  principal  one  in  the  pro- 
duction of  cardiac  insanity,  and  this  permits  us  to 
continue  to  consider  this  variety  of  alienation  as  a 
sympathetic  insanity  in  the  wider  sense  we  have 
given  to  the  term. 

All  diseases  of  the  heart  may  produce  mental 
alienation ;  but  those  whose  action  in  this  way  seems 
most  frequent  are  mitral  and  aortic  lesions.  The 
lesions  of  the  other  cardiac  orifices  may,  neverthe- 
less, have  a  certain  ro/e,  and  M.  Duplaix  has  re- 
ported in  V Encephale  a  case  of  insanity,  with 
agitation,  hallucinations  of  sight  and  hearing,  and 
ideas  of  persecution,  that  was  plainly  connected 
with  a  tricuspid  insufficiency. 

Cardiac  insanity  takes  on  most  frequently  the 
melancholic  form,  at  least  in  case  of  mitral  affec- 
tions, as,  according  to  certain  authors  and  especially 
M.  d' Astros,  who  has  supported  this  view,  the 
aortic  cases  are  those  of  the  excited  types,  and  the 
mitral  ones  the  depressed;  so  that  the  former  tend 
rather  to  mania  in  all  its  forms,  and  the  latter  to 
melancholia. 

The  depression  in  these  patients  reaches  occasion- 
ally the  condition  of  stupor;  the  tendency  to  suicide, 
already  noticed  by  Corvisart,  is  frequent;  there  is 


364       IXSAXITY  WITH  LOCAL  VISCERAL  DISEASE. 

finally  a  marked  tendency  to  impulsive  and  morbid 
acts,  such,  in  particular,  as  fits  of  passion  and  violence. 

The  delusions,  which  are  very  variable,  have  here 
no  special  type,  but  it  appears  nevertheless  that  per- 
secutory ideas  are  specially  common  in  cardiac  insan- 
ity, or  they  form  frequently  the  basis  of  the  insanity. 
As  regards  hallucinations  they  are  very  frequent 
in  this  mental  condition,  and  they  may,  in  this  case, 
have  some  relations  as  to  nature  and  character,  with 
the  organic  affection,  as,  for  example,  in  the  patient 
with  heart  disease,  I  have  elsewhere  referred  to,  who 
heard  a  voice  speaking  to  him  in  his  heart.  Deventer 
( Centralhlatt^  1888)  has  also  noted  the  existence  in 
cardiac  patients,  of  auditory  hallucinations  synchron- 
ous with  the  cardiac  beats. 

Cardiac  insanity  is  a  form  with  sudden  oscillations, 
intermittent  or  rather  remittent  in  its  conduct  and 
manifestations.  The  mental  disorders  are  commonly 
subordinate  to  the  influence  of  the  heart  affection. 
They  are  most  pronounced  at  the  times  of  exacer- 
bation of  the  bodily  disease.  Sometimes,  on  the 
other  hand,  we  observe  a  sort  of  inverse  equilibrium 
between  the  somatic  cardiac  disorder  and  the  intellec- 
tual troubles. 

Cardiac  insanity  is  serious,  because  its  cause,  the 
heart  affection,  is  permanent  and  incurable.  The 
attacks  of  insanity,  which,  as  has  been  remarked, 
usually  assume  the  intermittent  or  remittent  type, 
usually  are  recovered  from,  but  as  a  rule  they  re- 
appear and  they  are  very  liable  to  relapses. 


DISEASES  OF  THE  CIRCULATORY  APPARATUS.     365 

The  mental  disorders  that  sometimes  accompany 
the  later  stages  of  asystoly  have  not  been  mentioned. 
In  these  cases  we  do  not  have  a  real  insanity,  but 
a  sort  of  toxic  delirium  analogous  to  that  of  the  last 
stages  of  phthisis. 

In  a  recent  clinical  lecture  [Bulleti7i  Medical^ 
March,  1891),  M.  Huchard  has  sliown  that  true 
cardiac  insanity,  which  he  distinguishes  according 
as  it  occurs  with  or  without  asystoly,  is  compara- 
tively rare,  and  that  it  is  of  importance  not  to  con- 
found it  with  certain  deliriums  that  occur  in  patients 
with  cardiac  disease,  such  as  cardio-renal  delirium, 
due  at  once  to  asystoly  and  uraemia,  the  drug  delir- 
iums (digitalis,  belladonna,  etc.),  and  the  arthritic, 
alcoholic,  hysterical  and  puerperal  deliriums.  These 
various  forms  have  besides  a  physiognomy  of  their 
own  that  allows  them  to  be  recognized  with  proper 
attention. 

B. — Diseases  of  the  Blood- Vessels. 

Diseases  of  the  blood-vessels  rarely  give  rise  to  in- 
sanity properly  so-called.  We  have  in  these  cases 
more  of  dyscrasic  disorders  involving  the  intelligence, 
or,  more  frequently  still,  as  with  arterio-sclerosis, 
direct  cerebral  lesions  giving  rise  to  more  or  less 
pronounced  symptoms  of  dementia.  Occasionally, 
however,  we  meet  with  a  true  insanity,  made  up 
usually  of  hypochondriacal  ideas,  ideas  of  persecution 
and  accompanied  with  internal  hallucinations.  It 
is  in  c^ses  of  aortic  aneurism  especially  that  this  is 


36G       INSAXITT  WITH  LOCAL  VISCERAL  DISEASE. 

met  with,  as  has  been  recently  demonstrated  by  Dr. 
Mickle  {Brain,  1889). 

§  ly.     DISEASES  OF  THE  LUNGS. 

Except  in  tuberculosis,  the  mental  disorders  of 
which  are  studied  in  connection  with  the  insanities 
of  the  infectious  diseases,  the  local  affections  of  the 
lungs  are  only  exceptionally  accompanied  with  insan- 
ity, and  we  see  in  them  hardly  anything  more  than 
transitory  attacks  of  febrile  or  alcoholic  delirium. 


Cbapter  f  IF* 

INSANITIES  ASSOCIATED  WITH  GENERAL 
DISORDERS. 

(Acute  and  Chronic  Infectious  Diseases.  Diatheses). 


§1.     INSANITIES  OF  THE  INFECTIOUS  DISEASES. 

Infectious  diseases  may  aid  in  the  development  of 
insanity  by  a  triple  mechanism  recently  explained 
by  M.  Chardon  in  an  interesting  study  [Tlihse  de 
JLille^  1889.)  They  may  act:  (1)  by  the  direct  ac- 
tion of  the  microbes,  localized  in  the  nervous 
centres;  (2)  by  the  action  of  products  secreted  by 
the  microbes ;  (3)  by  auto-intoxication  by  products 
not  duly  eliminated  by  the  patient. 

Regarding  them  in  their  relations  with  mental 
alienation,  we  may  divide  the  infectious  diseases  into 
acute  and  chronic. 

"  Acute  Infectious  Diseases, 

(VABIOLA,  MEASLES,  SCARLATINA,  DTPHTHEKIA,   SWEATING  SICKNESS,  ERT- 
BIPELAS,  CHOLERA,  TYPHOID  FEVER,  HYDROPHOBIA,  INFLUENZA). 

1. —  Variola. 

The  eruptive  fever  most  frequently  complicated 
with  insanity  is  variola. 

The  times  when  this  complication  appears  are  by 
preference,  the  time  of  the  appearance  of  the  eruption 


3G8  INSANITIES  WITH  GENERAL  DISOKDEES. 

and  that  of  convalescence.  It  may  nevertheless  show 
itself  during  incubation  and  during  the  stage  of  sup- 
puration. 

The  most  usual  clinical  form  at  the  eruptive 
period  is  acute  mania  with  violent  agitation,  inco- 
herence, disordered  action,  active  fever;  at  conva- 
lescence, on  the  other  hand,  the  melancholic  form  is 
more  common,  generally  acute  or  subacute  melan- 
cholia, with  profound  depression  and  almost  always 
with  suicidal  tendencies.  The  frequency  of  suicide 
in  variolous  delirium  has  been  often  noted. 

The  attacks  of  insanity  connected  with  convales- 
cence from  small-pox  have  some  analogies  with  those 
we  observe  at  the  decline  of  typhoid  fever,  and  like 
those,  but  in  a  less  marked  degree,  they  present,  as 
regards  the  accompanying  delusions  and  hallucina- 
tions, a  stamp  of  absurdity  and  silliness  with  mental 
obtuseness  that  imprints  upon  them  an  altogether 
characteristic  physiognomy.  As  to  those  that  occur 
in  the  course  of  the  disease,  it  is  not  rare  to  see  them 
announced  by  a  decrease  of  the  febrile  symptoms 
which  may  be  mistaken  for  a  real  amelioration. 

The  prognosis  of  insanity  connected  with  variola 
is  generally  good  and  the  attack  is  commonly  re- 
covered from.  Nevertheless,  there  may  occur  a  fatal 
acute  delirium  in  the  eruptive  stage,  and  in  the  con- 
valescent stage  the  insanity  may  assume  a  chronic 
type  and  terminate  more  or  less  rapidly  in  dementia. 
We  need  not  mention  here  the  influence  of  variola 
on  the  course  of  a  pre-existing  insanity ;  that  subject 


ESrSANITIES  OF  THE  INFECTIOUS  DISEASES.        369 

appertains  to  general  pathology,  to  that  part  on  in- 
cidental affections.  We  will  confine  ourselves  to 
the  remark  that  variola,  and  in  a  general  way  all  the 
acute  febrile  disorders  may,  in  certain  cases  play  the 
part  of  crisis  and  bring  about  the  cure  or  the 
amelioration  of  the  insanity. 

Measles,  scarlatina  and  diphtheria  only  rarely  pro- 
voke an  attack  of  insanity  and  when  they  are  accom- 
panied with  intellectual  derangement,  it  is,  in  the 
first  named,  more  especially  a  febrile,  and  in  the 
last  a  sort  of  asj^hyxic  delirium  that  we  encounter. 
We  need  only  refer  also  to  sweating  sickness  in 
which  Brouardel  has  noted  the  possibility  of  maniacal 
or  melancholic  disorders.  (Epidemic  of  Poitou, 
1887). 

2. — Erysipelas. 

It  is  well  known  that  erysipelas,  especially  that  of 
the  face  and  scalp,  is  almost  constantly  accompanied 
with  a  febrile  or,  in  topers,  with  an  alcoholic  delirium 
In  a  few  rather  rare  cases  it  may  give  rise  to  an 
attack  of  genuine  insanity. 

As  in  variola,  the  attacks  of  insanity  in  erysipelas, 
occur  by  preference  in  the  acute  stage  of  the  dis- 
ease, nearly  always  under  the  form  of  acute  mania 
or  acute  delirium;  or  during  convalescence,  under 
the  form  of  melancholia  with  depression,  hebe- 
tude, various  hallucinations,  especially  of  hearing, 
ideas  of  suicide,  etc.,  etc.  General  paralysis  itself 
appears  to  be  developed  in  certain  cases,  after 
eiysipelas  of  the  face, 


370       rN"SAiaTiES  with  general  disordees. 

The  only  peculiarity  to  be  mentioned  in  connection 
with  insanity  due  to  erysipelas  is  that,  on  account 
of  erysipelas  being  a  disorder  likely  to  recur,  an 
attack  of  insanity  from  this  cause  creates  a  trouble- 
some precedent  that  makes  us  foresee  other  attacks 
in  case  of  the  recurrence  of  the  erysipelas.  There 
have  even  been  cases  reported  of  mania  following 
facial  erysipelas  cured  by  the  appearance  of  a  new 
er^^sipelatous  attack. 

3. — CJiolera. 

The  possibility  of  vesanic  complications  in  cholera, 
especially  at  the  period  of  convalescence  has  been 
often  noted.  The  more  usual  clinical  forms  are: 
acute  mania,  with  or  without  exalted  delusive  ideas, 
melancholia  accompanied  with  vague  ideas  of  per- 
secution and  tendency  to  suicide,  and,  lastly,  stupor. 

Although  insanity  is  a  complication  of  the  cholera, 
it  usually  recovers ;  indeed  it  has  been  remarked  that 
it  habitually  occurs  only  in  those  cases  of  cholera 
which  should  terminate  in  recovery. 

^. — Typlhoid  Femr. 

The  insanity  of  typhoid  fever  is  the  typical  in- 
sanity of  those  due  to  infectious  diseases.  On  ac- 
count of  its  importance,  its  relative  frequency,  and 
the  number  of  papers  its  study  has  caused  to  be 
written,  it  merits  our  attention. 

First  of  all  Ave  may  remark  that  febrile,  non- 
vesanic  delirium  is  very  common  in  typhoid  fever, 
and  is  never  lacking  in  severe   cases.     It  is  usually 


INSANITIES  OF  THE  INFECTIOUS  DISEASES.        371 

easy  to  recognize  by  the  febrile  characters  it  presents ; 
nevertheless  cases  have  been  reported,  and  this  seems 
rather  peculiar  to  typhoid  fever,  in  which  this  de- 
lirium becomes  systematized  and  made  up  entirely, 
so  to  speak,  of  hallucinations,  in  such  a  way  as  to 
offer  some  analogies  to  the  delirium  of  insanity. 

The  genuine  insanity  is  not  altogether  rare — 43 
cases  in  2,000  patients  (Nasse) ;  22  cases  in  500 
(Schlager) ;  11  cases  in  2,000  (Christian) — and,  as  in 
most  febrile  affections,  it  may  supervene  either 
during  the  course  of  the  disease  or  during  its 
decline. 

Marandon  de  Montyel  in  an  interesting  paper, 
has  made  a  classification  of  the  deliriums  of  typhoid 
fever,  which  he  divides  into  pertyphic  deliriums, 
comprising  those  of  the  initial  stage,  the  period 
of  culmination  and,  that  of  convalescence,  and 
Xh'^post  typ)liic  deliriums  either  mediate  or  immediate. 
All  these  divisions,  although  they  have  been  ac- 
cepted by  some  authorities,  seem  to  me  unnecessary, 
and  I  limit  myself  to  admitting  one  insanity  occur- 
ring in  the  course  of  the  dothienteritis,  or  a  pertyphic 
insanity  and  one  of  convalescene  or  a  post-typhic 
insanity. 

Pertyphic  insanity  is  rather  rare.  It  consists 
almost  always  in  an  acute  or  hyperacute  mania  com- 
bined with  phenomena  of  excitement  and  depression. 
These  attacks,  as  has  been  remarked  when  speaking 
of  the  eruptive  fevers,  may  announce  themselves  by 
illusive  symptoms  of  improvement.     According  to 


372  IXSAXITIES  WITH  GENERAL  DISOEDEES. 

Kroepelin  they  are  followed  by  death  in  at  least  one 
quarter  of  the  cases. 

Post-typhic  insanity,  or  that  of  convalescence,  is 
more  common.  The  time  of  its  appearance  is  vari- 
able. It  may  appear  either  at  the  decline  of  the  dis- 
ease, when  the  febrile  movement  becomes  less  intense, 
or  later,  during  convalescence.  It  may  even  show 
itself  after  apparent  restoration  of  health  and  when 
the  patient  has  been  out  repeatedly. 

The  appearance  of  insanity  after  typhoid  fever  does 
not  necessarily  indicate  that  the  affection  has  been 
very  severe  or  that  it  has  been  of  the  adjmamic  type; 
it  may  occur  even  after  mild  cases  of  short  duration. 
As  has  been  recently  said  with  truth,  insanity  is  more 
frequent  in  certain  epidemics  of  typhoid  than  in 
others,  which  fact  seems  to  indicate  that,  aside  from 
individual  predispositions,  certain  epidemics  seem  to 
be  specially  predisposed  to  this  complication. 

The  three  states  of  alienation  that  may  occur  in 
the  decline  of  tj^phoid  are:  intellectual  obtuseness 
or  pseudo-dementia,  mania,  and  melancholia. 

Intellectual  obtusion  is  only  the  morbid  exaggera- 
tion of  the  more  or  less  marked  and  persistent 
obscuration  of  the  faculties  and  especially  of  the 
mempry,  that  is  commonly  left  behind  it  by  typhoid 
fever.  In  this  case  it  presents  itself  with  all  the 
features  of  dementia,  and  may  extend,  in  some 
cases,  as  far  as  the  complete  abolition  of  the  intelli- 
gence. This  is  not,  however,  a  true  dementia ;  it  is 
only  a  pseudo-dementia,  an  obscuration  of  the  mind 


INSANITIES  OP  THE  INFECTIOUS  DISEASES.       373 

by  excessive  debilitation  of  the  brain,  since  in  al- 
most all  cases  the  mental  faculties  arouse  themselves 
more  or  less  completely  to  their  normal  activity, 
while  the  alterations  of  dementia  are  irreparable. 

This  intellectual'  obtusion  or  pseudo-dementia  may 
alone  constitute  the  whole  mental  trouble,  but  it  ex- 
ists even  when  mania  or  melancholia  follows  the 
fever,  and  it  is  the  feature  that  forms  one  of  the 
principal  characteristics  of  this  kind  of  insanity. 

Mania,  in  typhoid  fcA^er,  occurs  in  the  acute  form 
and  more  commonly  still  in  the  sub-acute  form.  The 
frequency  of  more  or  less  limited  ideas  of  ambition 
has  been  long  since  observed  in  these  cases. 

The  special  character  that  gives  to  this  condition 
and  this  form  of  insanity  a  special  physiognomy,  is 
the  constantly  existing  intellectual  obtusion.  This, 
indeed,  causes  a  condition  of  hebetude  and  mental 
weakness  that  imprints  on  the  whole  mental  dis- 
order, the  ideas  and  acts  a  stamp  of  characteristic 
absurdity  and  stupidity.  This  peculiarity,  together 
with  what  we  have  said  regarding  the  relative  fre- 
quency in  these  cases  of  ambitious  and  absurd  con- 
ceptions, and  also  the  physical  disorders,  such  as 
muscular  weakness,  tremor,  slowness  of  speech, 
which  may  concurrently  exist,  may  all  together  oc- 
casionally give  rise  to  some  difficulties  in  the  diag- 
nosis of  this  condition  from  general  paralysis. 

The  most  frequent  form  of  insanity  in  the  con- 
valescence from  typhoid  fever  is  mehmcholia.  It  is 
commonly  characterized  by  a  more  or  less  profound 


374         1K"SAX1TI£S  WITH  GEIfEtlAL  DISOEDEliS. 

depression,  going  in  some  cases  as  far  as  to  stupor; 
by  confused  hallucinations,  especiall}' of  hearing;  by- 
delusions,  chiefl}^  vague  ones  of  persecution  or  mys- 
ticism ;  and  lastly  by  foolish  acts  and  sometimes  a 
marked  tendency  to  sitiophobia  and  suicide.  As  with 
mania,  that  which  gives  it  its  special  note,  is  the 
character  of  dementia  that  presents  itself  in  all  its 
symptoms  and  manifestations. 

Summing  up,  the  mental  disorder  of  the  convales- 
cence from  typhoid  fever  may  be  described  as  a  con- 
stant condition  of  pseudo-dementia,  which  forms  the 
basis  of  the  intellectual  condition,  and  upon  which 
sometimes  supervene  more  or  less  acute  attacks  of 
mania  or  melancholia. 

Peogxosis. — In  spite  of  the  bodily  debility  that 
accompanies  this  condition  and  in  spite  of  tlie  ap- 
parent gravity  of  the  attacks  they  most  generally 
end  in  recovery,  and  it  is  the  rule  to  see  the  insanity 
following  typhoid  fever  disappear.  It  is  only  in 
rare  cases  that  it  persists  and  passes  into  the  chronic 
condition. 

Pathogeny. — While  nothing  is  absolutely  certain 
as  regards  this,  it  is  probable  that  the  pseudo-de- 
mentia and  attacks  of  insanity  in  the  convalescence 
from  typhoid  fever  are  connected  with  dynamic  and 
nutritive  disorders  of  the  nervous  substance  of  the 
brain. 

Diagnosis. — Insanity  following  typhoid  fever  is 
rather   readily  recognized  by  the  character  of  de- 


INSANITIES  OF  THE  INFECTIOUS  DISEASES.       375 

mentia  it  presents,  the  general  obtusion  of  the  whole 
mental  condition  of  the  patient  that  is  its  chief 
characteristic.  A  correct  diagnosis  is  therefore 
comparatively  easy  even  in  the  absence  of  any  full 
history.  An  important  matter  sometimes  is  to  dis- 
tinguish between  the  insanity  from  typhoid  and  a 
general  paralysis  of  the  maniacal  or  melancholic 
type,  the  more  so  since  general  paralysis  may  follow 
typhoid  fever.  The  difficulty  is  sometimes  great 
enough  to  cause  some  hesitation.  Nevertheless,  one 
can  generally  rely  on  the  fact  that  embarrassment  of 
speech  and  inequality  of  the  pupils  are  commonly 
lacking  in  typhoid  fever,  and  that  the  delusions  are 
more  childish,  silly,  and  limited,  and  less  mobile 
than  they  are  in  general  paralysis.  As  to  the  de- 
lirium that  sometimes  occurs  in  the  beginning  of 
typhoid  fever,  it  may  be  mistaken  for  an  attack  of 
insanity,  and  this  error  has  been  committed.  It  is 
needful  as  a  general  rule  to  distrust  the  deliriums 
that  appear  suddenly  complicating  a  fever,  especi- 
ally one  with  an  evening  exacerbation  and  a  regularly 
ascending  temperature  curve,  which  are  usually  only 
febrile  deliriums.  According  to  Marandon  de  Mon- 
tyel,  the  rejection  with  disgust  of  liquids  is  the  best 
differential  sign  of  acute  delirium  from  typhoid  fever 
and  the  beo-innimy  of  maniacal  delirium. 

The  treatment  varies  according  to  the  case ;  the 
chief  indication  is  to  tone  up  the  system  of  the 
patient  in  every  way,  with  bitter  tonics,  hydro- 
therapy, exercises,  etc. 


376         INSANITIES  WITH  GENERAL  DISOEDERS. 

5.  — Hydro2')lioMa. 

The  mental  disorders  connected  with  rabies,  de- 
scribed b}'  Brierre  de  Boismont,  have  been  the  sub- 
jects t>f  special  studies  of  late  years  by  Pierret, 
Belous  and  Chardon. 

In  the  beginning  are  observ.ed  insomnia,  a  special 
form  of  headache  (sensation  of  the  head  in  a  vice), 
nightmare,  general  excitation  of  the  organism  with 
desire  of  locomotion,  disorders  of  secretion  and  of 
the  saliva  in  particular. 

Next  appear  the  phenomena  of  agitation  with  hal- 
lucinations, illusions,  and  delirium  resembling  alco- 
holism. It  is  a  plainly  maniacal  condition ;  the  patient 
breaks  and  destroj^s  everything,  makes  gestures  and 
utters  cries  according  to  his  hallucinations  and 
illusions. 

This  period  of  general  excitement  of  the  nervous 
system  is  followed  by  a  period  of  depression  and 
paralj^sis.  Then  follow  the  typhoid  phenomena  and 
death  ends  the  scene. 

Professor  Pierret  lays  much  stress  upon  multi- 
ple paralysis,  especially  those  of  the  jaws  and  of 
the  pharynx,  as  characteristics  of  hydrophobic 
delirium. 

6. — Gri])pe  or  Iiiflxienza. 

The  relations  of  insanity  with  influenza  were  but 
little  studied  prior  to  the  late  pandemic,  a  few 
authors,  such  as  Rush  (1790)  and  Bonnet,  of  Bor- 
deaux (1837),  have  merely  noted  the  possibility  of 


INSANITIES  OP  THE  rNTECTIOrS  DISEASES.       377 

the  appearance  of  mental  alienation  in  consequence 
of  the  grippe. 

The  epidemic  of  1889-90,  either  because  of  its 
assuming  a  special  character,  or  because  the  facts 
were  better  observed,  has  been  noticeably  accom- 
panied by  a  great  number  of  cases  of  neuropathic 
or  psychopathic  disorders.  It  seems  from  the  mem- 
oirs published  on  the  subject  by  French  and  foreign 
authors,  notably  by  Huchard,  Joffroy,  Krsepelin, 
Metz,  Bartels,  Pick,  Mairet,  Ladame,  etc.,  that 
the  insanity  in  influenza  behaves  exactly  like 
that  of  typhoid  fever.  Sometimes  it  appears 
with  the  fever  in  the  beginning,  or  even  before 
the  grippal  '  symptoms ;  sometimes  on  the  other 
hand,  and  this  is  more  common,  during  conva- 
lescence. In  the  first  case  we  have  usually  a 
violent  maniacal  attack  with  automatic  agitation, 
ordinarily  of  short  duration.  In  the  second  case, 
and  in  that  form  specially  studied  by  Ladame  under 
the  name  of  post-grippal psychosis^  we  have  to  do 
with  the  phenomena  of  cerebral  neurasthenia,  char- 
acterized by  hebetude  and  torpor,  it  may  be  with 
actual  melancholic  or  hypochondriacal  attacks  with 
more  or  less  pronounced  mental  obtusion. 

In  almost  all  cases  the  effects  of  the  influenza  are 
combined  with  hereditary  predisposition.  Xearly 
always  also,  the  mental  disorders,  serious  as  they 
appear,  recover  more  or  less  quickly  under  the  in- 
fluence of  a  proper,  and  especially  a  tonic,  medica- 
tion. 

MSKT.  M£I>.— 24. 


378       1NSA^^TIES  with  general  disorders. 

The  action  of  influenza  on  the  insane  themselves 
has  been  very  variable.  In  some  asj^lums  the 
patients  appeared  altogether  refractory  to  the  epi- 
demic, even  when  the  personnel  suffered  severely; 
in  others  they  were  attacked  in  great  numbers  by 
the  disease,  without,  as  a  rule,  its  exerting  any  action 
whatever  on  the  pre-existing  insanity. 

CHRONIC    INFECTIOUS   DISEASES. 

(CNTEB3HTTENT  FEVER,  TUBERCULOSIS,  PELLAGRA,   SYPHILIS). 

1. — Intermittent  Fever. 
{Paludal  Insanity.) 

Sydenham  was  the  first  to  remark  the  possibility 
of  insanity  being  due  to  intermittent  fever.  Since 
then,  a  great  number  of  observers  (Sebastian,  Bail- 
larger,  Billod,  Griesinger,  Krsepelin,  Laveran, 
Bard,  etc).,  have  taken  up  the  subject,  but  it  is 
Professor  Lemoine  who  has,  of  late  years,  made  the 
most  complete  study  of  it.  (Lemoine  and  Chaumier, 
Annales  3Iedico-2)sychologiques^  1887). 

We  recognize  with  him:  (1)  the  psychic  disorders 
of  the  febrile  attack;  (2)  those  of  convalescence  from 
intermittent  fever;  (3)  those  of  chronic  malarial 
poisoning. 

1.  The  attack  of  intermittent  fever,  even  in  its 
least  degree,  may,  in  nervous  or  debilitated  individ- 
uals, be  accompanied  with  insanity.  It  is  then  a 
more  or  less  noisy  delirium,  but  essentially  fugaci- 
ous and  sometimes  periodic.     It  is  in  the  pernicious 


CHRONIC  INFECTIOUS  DISEASES.  879 

attacks  tliat  tlic  psycliic  troubles  arc  most  intense 
and  dominate  all  other  symptoms  to  tlie  extent  of 
effacing  them  and  making  the  diagnosis  difficult. 
After  two  or  three  febrile  attacks  accompanied  by 
general  excitement,  headache,  and  cries  of  pain,  the 
insanity  makes  its  outbreak  under  the  form  of  acute 
mania,  ^'iie  agitation  is  excessive,  the  face  flushed, 
the  pupils  dilated,  the  arterial  pulse  strong,  and 
these  symptoms  increase  in  intensity  until  coma  or 
convulsions  appear.  Sometimes  there  is  observed 
a  series  of  alternating  phases  of  excitement  and 
stupor.  When  a  favorable  termination  is  about  to 
occur,  general  perspiration  covers  the  body,  the 
patient  becomes  drowsy  and  goes  to  sleep ;  when  it  is 
to  end  unfavorabl}^  coma  supervenes  and  death 
ensues. 

Instead  of  coming  on  gradually  the  insanity  may 
break  out  suddenly,  noisy  and  violent,  especially  in 
the  night.  Finally,  it  may  be  accompanied  with 
convulsions,  transitory  paralysis,  and  aphasia,  and 
be  followed  by  a  more  or  less  persistent  condition 
of  hebetude  after  recovery. 

2.  The  mental  disorders  occurring  during  con- 
valescence from  malarial  fevers  are  better  known. 
Sometimes  they  appear  immediately  after  the 
disappearance  of  the  malarial  attacks  or  even 
while  the}^  are  still  occurring,  but  more  often 
they  appear  only  in  that  period  of  indefinite  duration 
in  which  the  anaemic,  enfeebled,  and  anorexic  patient 
is  in  constant  danger  of  a  relapse. 


380         rN"SAXITIES  WITH  GENERAL  DISORDEES. 

AccordiDg  to  Sebastian  and  Baillarger  the  most  f re- 
quentl}'  observed  form  is  stupor.  It  lasts  for  a  varia- 
ble period  but  recovery  almost  always  occurs  when  the 
patient  has  regained  his  strength,  has  recovered  from 
the  anaemia,  and  has  thrown  off  the  fever. 

Mania  has  also  been  observed  at  this  period,  and 
Krgepelin  has  met  with  it  alone,  often  accompanied 
with  exalted  delusions.  The  prognosis  here  is  more 
sombre,  and  recovery,  when  it  does  occur,  is  always 
delayed. 

Sebastian  finally,  has  described  a  form,  character- 
ized by  attacks  of  insanity  occurring  every  one  or 
two  days,  at  the  same  hour  and  after  the  same  fash- 
ion as  the  preceding  fever.  The  mania  especially 
has  a  character  of  periodicity,  and  is  cured  by  the 
use  of  sulphate  of  quinine.  Since  Sebastian  there 
have  been  no  cases  published  in  which  an  intermit- 
tent insanity  replaced  the  febrile  attacks,  but,  as  M. 
Lemoine  remarks,  a  certain  number  of  cases  in  which 
patients  not  suffering  from  malaria,  presenting  hal- 
lucinations or  insanity  with  regular  intermissions 
and  cured  by  quinine,  may  be  regarded  as  special 
larvated  accidents  of  a  sensorial  type. 

3.  The  psychic  disorders  connected  with  chronic 
malarial  poisoning  have  hardly  been  studied  at  all 
except  by  Krajpelin  and  Lemoine.  The  last  named 
has  called  attention  to  the  cases  where  mental  de- 
rangement, although  occurring  in  non-cachectic 
individuals,  is  connected  with  former  attacks  of  in- 
termittent fever  by  a  series  of    larvated  phenom- 


CHEOXIC  INFECTIOUS  DISEASES.  381 

ena  that  leave  no  doubt  of  its  malarial  nature.  In 
some  cases,  moreover,  as  if  to  confirm  the  diagnosis, 
the  latent  febrile  symptoms  reappear  and  bring  with 
them  an  exacerbation  of  the  insanity.  The  insanity 
of  these  patients  is  variable  iu  type,  resistent  to 
quinine,  chronic  and  without  any  tendency  to  re- 
covery. 

M.  Lemoine  thinks  that  malaria,  when  super- 
imposed on  an  arthritic  basis,  may  cause  in  the  long 
run,  the  lesions  and  consequently  the  symptoms  of 
general  paralysis,  but  the  observed  facts  are  still  too 
few  to  permit  the  settlement  of  the  question. 

2. — Tuberculosis. 

{Lisanity  of  Tinerculosis). 

Esquirol  and  Georget  long  ago  remarked  the  fre- 
quency of  chest  affections  in  the  insane.  Since  then, 
this  interesting  subject  has  led  to  the  production  of 
numerous  works,  notably  those  of  Burrows  and  Ellis, 
Friedreich,  Schroeder  van  der  iTolk,  Skae,  Clouston, 
Biaute,  Ball,  etc.,  Vv^hence  it  is  clearly  shown  that 
lung  diseases,  and  tuberculosis  in  particular,  have  a 
marked  influence  on  disorders  of  the  mind. 

In  many  consumptives  the  intellect  and  character 
arc  more  or  less  affected.  Sometimes  we  see  an  ab- 
normal tendency  to  hypochondria  or  sadness,  or  on 
the  other  hand,  to  satisfaction,  to  optimism,  to  a 
feeling  of  well-being,  to  enplioria^  as  it  has  been 
called.  The  patients  become  irritable,  mobile  to 
excess,  often  also  they  give  evidence  of  a  remarkable 


3S2         IXSAXITIES  WITH  GENERAL  DISORDERS. 

gencsic  excitation.  Lastly  tliey  ma}^  give  themselves 
to  the  comraission  of  morbid  acts  and  to  true  impul- 
sions, dipsomania  for  example. 

As  regards  genuine  insanity,  it  may  occur  in  tuber- 
culous cases  in  many  diffcn-ent  ways.  Sometimes  the 
tubercular  infection  manifestly  antedates  the  insau- 
it}',  which,  once  established,  undergoes  the  same  vicis- 
situdes as  tliG  bodily  disorder  and  follows  a  parallel 
course.  In  other  cases  the  appearance  of  the  mental 
disorder  coincides  with  the  amendment  or  the  disap- 
IjesLYSLUCQ  of  the  j^ulmonary  symptoms  and  then  we 
see  the  two  kinds  of  phenomena  alternate  and  replace 
each  other.  In  other  cases,  finally,  the  insanity 
breaks  out  suddenly  without  there  having  been  any 
prior  indication  to  call  attention  to  the  state  of  the 
lungs,  the  phthisis  having  up  to  the  time  taken  on 
the  latent  form  it  so  frequently  aspects  in  the  insane, 
and  to  which  the  English  liave  given  the  name 
"  florid  consumption"  on  account  of  the  appearance 
of  the.  patient  and  the  coloration  of  the  face,  which 
affords  a  striking  contrast  with  the  data  obtained 
by  auscultation. 

It  is  necessary  to  notice,  finallj^,  the  attacks  of 
more  or  less  transitory  insanity  or  delirium  that 
occur  in  tuberculous  patients  in  the  last  stages  of  their 
disorder,  and  of  which  MM.  Peter,  Lucien,  Leudet, 
and  B.  Ball  have  reported  interesting  examples. 
Here,  liowever,  as  has  been  shown  by  these  authors, 
we  have  to  do  only  with  toxic  phenomena  due  to 
deficient  hamatosis  and  to  saturation  of  the  blood 


CHRONIC  IXFECTIOUS  DISE.VSKS.  383 

with  carbonic  acid,  that  is  to  say  with  a  delirium 
that  lias  nothing  really  to  do  with  insanity  properly 
so-called. 

Whatever  its  mode  of  commencement,  the  attack 
of  insanit}^  connected  with  phthisis  is  variable  in  its 
character.  It  is  generally  admitted,  however,  that 
its  most  frequent  form  is  that  of  lypemania. 

Dr.  Chjuston  pushing  his  analysis  still  further, 
makes  out  that  of  all  the  varieties  of  alienation,  the 
most  frequent  one  in  consumptives  is  the  mania  of 
suspicion  (he  might  belter  say  the  melancholia  of 
suspicion).  He  adds  also  that  this  monomania  of 
distrust  is  more  common  in  tuberculosis  of  the  peri- 
toneum than  in  that  of  the  lungs.  M.  Ball  has 
given  in  his  Lemons  a  remarkable  example  of  this 
kind  of  insanity. 

After  this  melancholia  of  suspicion,  which  often 
presents  itself  imder  the  form  of  lucid  or  conscious 
insanity,  the  most  common  form  in  pulmonary 
phthisis  is  acute  melancholia,  especially  profound 
melancholia,  accompanied  with  suicidal  tendencies 
that  persist  for  a  long  time,  and  refusal  of  food. 
Mania  and  dementia  follow  after,  and  finally  at  the 
bottom  of  the  scale  comes  general  paralysis. 

Without  discussing  the  question  how  tuberculosis 
can  of  itself  create  this  disorder,  it  is  certain  that, 
whether  latent  or  not,  and  it  is  generally  latent,  the 
pulmonary  affection  influences  the  mental  aspect  of 
the  general  paralysis.  Clouston  has  remarked  that 
all  tuberculous  paretics  began   with  a  melancholic 


384       rN•sA^^TIEs  with  general  disobdees. 

stage  and  that  it  is  in  tliese  especially  that  we 
meet  with  the  extravagant  hypochondriacal  ideas 
described  by  M.  Baillarger. 

In  those  cases  where  the  insanity  presents  itself  in 
its  most  frequent  form,  the  following  is,  according  to 
Clouston,  as  reported  by  M.  Ball,  the  usual  method 
of  its  manifestations. 

The  initial  insanity  appears  as  a  mania  or  melan- 
cholia. We  observe  excitement  or  depression,  but 
the  acute  stage  soon  disappears  and  the  patient  falls 
into  the  chronic  condition.  He  manifests  an  alto- 
gether peculiar  mental  condition ;  he  is  the  prey  of 
morbid  irritability,  a  continual  bad  humor.  He 
is  troubled  with  a  mania  of  suspicion,  and  presents, 
so  to  speak,  a  false  insanity  of  persecution.  There 
is  simultaneously  a  sort  of  mental  weakness,  a  pro- 
found aversion  to  work,  a  horror  of  movement. 

This  condition  of  depression  is  often  traversed  by 
fits  of  passion.  The  patient  becomes  suddenly 
angered  without  any  reason,  but  his  irritation  does 
not  long  continue. 

Little  by  little  the  subject  falls  into  a  serai-de- 
mented state,  interrupted  sometimes  by  periodic  re- 
missions, flashes  of  intelligence  now  and  then  appear 
and  it  is  in  these  consumptive  insane,  especially,  that 
we  observe  that  singular  return  to  rationality  on  the 
approach  of  dissolution  that  has  been  noticed  by  so 
many  observers. 

The  cerebral  lesions  of  phthisical  insanity  present 
no  striking  peculiarities.      According  to  Schiile  there 


CHEONIC  INT^ECTIOtJS  DISEASES.  385 

is  often  a  venous  hypersemia  of  the  meninges  with 
anaemia  of  the  underlying  cortical  substance.  The 
brain  is  pale  and  oedematous  and  shows  here  and 
there  vascular  irregularities.  Under  the  microscope 
we  find,  fatty  infiltration  and  rupture  of  some  corti- 
cal fibres.  According  to  Clouston  also,  the  specific 
weight  of  the  gray  matter  is  very  much  diminished. 

The  insanity  of  consumptives  is,  as  a  rule,  in- 
curable. Half  of  the  patients  succumb  within  three 
years  from  the  commencement  of  the  insanity. 
Finally,  it  only  very  rarely  has  any  favorable  re- 
action upon  the  phthisis,  and  in  the  vast  majority 
of  cases,  although  the  symptoms  of  phthisis  remain 
masked,  the  bacillary  evolution  none  the  less  pursues 
its  course. 

The  treatment  is  that  of  pulmonary  phthisis.  It 
is  needful,  however,  to  keep  in  mind  that  the  insan- 
ity may  alternate  with  the  lung  symptoms  and  that 
the  disappearance  of  the  one  may  cause  the  others 
to  disappear,  which  fact  renders  great  caution  ad- 
visable. 

3. — Pellagra. 
{Pellagrous  Insanity,  Pellagrous  General  Paralysis). 

Pellagra,  as  is  well  known,  is  a  chronic  infectious 
malady,  characterized  essentially  by  a  squamous 
erythema,  limited  to  the  parts  most  exposed  to  light 
and  heat,  by  a  chronic  phlegmasia  of  the  digestive 
tracts,  the  principal  symptom  of  which  is  an  obsti- 
nate diarrhoea,  and,  lastly,  by  a  more  or  less  grave 


380  IXSAXITIES  VriTU  GENERAL  DISORDEES. 

lesion  of  the  nervous  system,  sometimes  terminatinoj 
in  mental  alienation  and  paralysis  (Henry  Gintrac). 
AVe  need  not  liere  take  up  the  question  of  etiology 
that  has  given  rise  to  so  many  and  so  long  discus- 
sions both  in  France  and  Italy.  It  may  only  be  re- 
marked that  atmospheric  and  geological  causes, 
heredity,  and  especially  the  use  of  maize  altered  by 
a  parasite  called  verderame  or  verdet^  have  all  in 
turn  been  charged  with  its  origination.  From  all 
the  facts  known,  we  may  admit,  with  Lombroso, 
that  pellagra  is  the  result  of  a  special  poisoning  of 
the  organism  by  certain  alkaloids  of  altered  maize 
{jnalsme). 

Pmllagrous  Ixsaxity. —  As  far  as  the  mental 
symptoms  are  concerned,  it  is  generally  recognized 
that  the  most  frequent  form  of  mental  alienation  in 
pellagra,  is  melancholia.  It  .exists,  to  a  greater  or 
less  degree,  in  most  cases.  It  reveals  itself  by  an 
inertia,  apassiveness,  an  indifference,  a  rather  marked 
torpidity;  hj  insomnia,  hallucinations,  often  of  a 
terrifying  nature,  of  sight  and  also  of  hearing;  by 
depressive  delusions  and  fixed  ideas  of  despair,  fear 
and  anxiety,  and  in  particular  so  marked  a  tendency 
to  suicide  and  to  suicide  by  drowning,  that  Strambio 
has  described  the  disorder  under  the  name  of 
hydromania.  In  looking  over  the  records  of  the 
countries  where  pellagra  prevails  one  readily  notices 
how  many  cases  are  found  drowned  each  year. 
This  melancholic  depression,  which  in  some  cases 


CHRONIC  INFECTIOUS  DISEASES.  387 

may  attain  to  stupor,  has  always  a  basis  of  obtusion, 
of  intellectual  hebetude,  that  finally  becomes  per- 
manent, and  gradually  terminates  in  dementia,  as  the 
pellagrous  cachexia  progresses. 

Pellagrous  Gen-eral  Paralysis. — M.  Baillar- 
ger  and  some  Italian  authors  have  described  a 
special  form  of  general  paralysis,  consecutive  to  the 
pellagrous  cachexia,  the  dominant  mental  syrajitoms 
of  which  are  dementia  and  depressive  ideas.  From 
the  numerous  wiitings  and  discussions  on  this  point 
it  is  tolerably  generally  agreed  to-day  that  w-e  do 
not  have  to  do  in  these  cases  with  a  true  general 
paralysis,  but  rather  with  a  pseudo-general  paral- 
ysis, with  rather  infrequent  embarrassments  of 
speech ;  much  such  as  is  observed  in  the  course  of 
syphilitic  disease,  or  in  certain  chronic  intoxications 
such  as  saturnism  or  alcoholism  (Baillarger,  Annales 
Med.  2osychol.,  1888). 

Pellagra  in  the  Insane. — M.  Billod  noticed,  in 
1855,  an  epidemic  of  pellagra  in  the  asylums  of 
Ille-et-'Yilalne  and  Mai ne-et- Loire,  and  since  then  in 
numerous  papers  he  has  maintained  the  possibility  of 
the  development  of  this  disease  during  the  course  of 
mental  alienation.  It  is,  however,  generally  agreed 
that  the  erythema  and  various  other  troubles  that 
were  presented  by  these  insane  are  a  pseudo-pellagra 
and  not  a  true  pellagra. 

Pellagrous  insanity  is  one  of  the  most  grave  vari- 
eties, not  in  itself,  but  because  it  is  the  expression. 


388       r^-SA^TnEs  with  gexekal  disordees. 

in  the  sphere  of  the  intelligeuce  of  a  general  disease, 
progressive  in  its  course,  and  inevitably  ending  in 
cachexia  and  death. 

The  diagnosis  of  pellagrous  insanity  need  not  be 
at  all  doubtful,  on  account  of  the  other  symptoms 
of  th(;  general  disorder.  It  presents  no  special  in- 
dications as  regards  treatment  which  is  that  of  the 
pellagra  itself. 

4. — Syphilis. 
{Syphilitic  Insanity,  SypJiilitic  Pseiido-  General  Paralysis). 

The  question  of  the  relations  of  syphilis  and  men- 
tal alienation  includes  two  factors :  (1)  syphilis  and 
insanity ;  (2)  syphilis  and  general  paralysis.  These 
two  parts  of  the  problem  have  been  long  studied 
abroad ;  in  France  only  the  latter,  and  that  of  recent 
times,  has  received  much  attention. 

1.  Syphilis  and  Insanity. — In  a  rather  large 
number  of  syphilitic  cases  the  morale  is  more  or  less 
profoundly  altered;  there  are  depression,  moroseness, 
hypochondria,  melancholic  prepossessions,  disgust 
with  life,  and  sometimes  even  a  tendency  to  suicide. 
This  is  what  we  may  call,  from  its  analogy  with 
the  rudimentary  psychic  troubles  of  certain  diatheses, 
the  'mental  state  in  syphilis. 

The  insanity  of  syphilis,  as  appears  from  the  in- 
teresting historical  studies  of  Morel-Lavallue  and 
Bclieres  and  of  Parant,  has  been  specially  studied 
during  the  past  twenty  years,  by  J.  F.  Duncan, 
Grainger  Stewart,  Wille,  Skae  and  Clouston,  Hayes 


CHEONIC  rN-FECTIOUS  DISEASES.  389 

Newington,  Julius  Mickle,  Alf.  Foumier,  Kiernan, 
Goldamith,  Savage,  Wiglesworth,  Kinnier,  and  more 
recently  by  the  English  and  American  alienists  at 
the  Congress  of  Washington  (1887).  The  predom- 
inant opinion  is  that  syphilis  may,  in  certain  cases, 
cause  or  favor  the  appearance  of  insanity  but  that 
this  insanity  thus  produced  does  not  present  any 
special  characters,  that  there  is  no  syphilitic  insanity 
properly  so  called.  Generally,  moreover,  syphilis 
does  not  act  alone  in  these  cases,  and  there  is  almost 
always  hereditary  predisposition  and  also  other  oc- 
casional causes. 

Insanity  may  appear  either  in  the  first  stages  of 
syphilis  or  by  preference  during  the  secondary  or 
tertiary  stages. 

That  occurring  at  the  period  of  infection  is  very 
rare.  Goldsmith  and  Savage,  who  have  reported  a 
few  cases,  attribute  it  rather  to  the  moral  influence 
than  'to  the  specific  effect  of  the  disease. 

The  insanity  of  the  secondaiy  stage  is  more  com- 
mon. It  appears  especially  with  the  accidents  ac- 
companied by  fever,  principally  at  the  time  of  the 
cutaneous  eruiDtions.  It  is  then  an  acute  or  subacute 
attack  of  mania  or  melancliolia,  generally  of  short 
duration  and  quickly  yielding  to  specific  treatment. 

Its  etiology  may  be  attributed  to  multiple  causes, 
cachectic  condition,  mercurialization,  poisoning, 
hyperthermy,  etc. 

The  insanity  of  the  tertiary  stage,  or  late  insanity 
of  syphilis  has  been  elucidated  by  Professor  Fournier 


390  INSANITIES  TV^TH  GENERAL  DTSOKDERS. 

under  the  name  of  the  mental  type  of  cerebral  syph- 
ilis.    It  is  the  form  most  frequently  met  with. 

It  ordinarily  consists  in  a  more  or  less  acutely 
melancholic  state  -with  various  delusions,  with  pre- 
dominating hypochondriacal  ideas,  notions  of  per- 
secution and  poisoning,  confused  hallucinations  of 
taste,  smell,  and  hearing,  refusal  of  food,  and  tend- 
ency to  suicide.  This  is  the  depressive  form  of 
Fournier.  At  other  times  (expansive  form)  it  consists 
in  a  maniacal  condition,  ranging  from  simple  cere- 
bral excitement  to  acute  mania  with  automatic  a^ita- 
tion,  incoherence,  and  violence.  There  is  joined  to 
the  vesanic  condition  nearly  always  a  mental  torpor 
and  obtusion  of  the  faculties,  that  imprints  a  char- 
acteristic stamp  of  hebetude  on  the  manifestations  of 
the  insanity,  whatever  its  form.  Often,  indeed, 
the  mental  disorder  is  limited  almost  solel}'-  to  this 
obtusion  characterized  by  a  sort  of  external  stupidity 
with  apparent  loss  of  ideas,  recollections  and  senti- 
ments, and  which  deserves,  from  its  importance  and 
frequency,  to  constitute  a  third  form  of  mental 
syphilis  under  the  name  of  the  pseudo-demented  or 
tor})id  form. 

The  insanity  of  tertiary  syphilis  is  usually  due  to 
the  action  on  the  brain  of  more  or  less  circumscribed 
specific  lesions,  such  as  gummata,  arteritis,  meningo- 
encephalitis, etc.  Nevertheless,  and  Mickle  lays 
stress  on  tliis  point,  it  may  develop  without  any 
alteration  in  the  nerve  centres  and  when  onl}''  the 
other  organs  are  seriously  affected  by  syphilis. 


CHRONIC  rNFECTIOUS  DISEASES.  391 

In  the  great  majority  of  cases  the  late  insanity  of 
syphilis  is  recovered  from,  but  there  is  often  left  a 
more  or  less  marked  degree  of  mental  weakness. 

The  diagnosis,  difficult  when  the  external  man- 
ifestations of  syphilis  are  lacking,  must  be  made  from 
the  antecedents  which  must  be  sought  for  with  the 
utmost  care.  In  dubious  cases  resort  should  be  had 
to  specific  treatment,  which  is  sometimes  a  veritable 
touchstone.  That  is  to  say,  the  insanity  of  ter- 
tiary syphilis,  in  spite  of  its  apparent  gravity,  is 
very  amenable  to  specific  treatment  which  should 
in  the  main,  consists  of  repeated  mercurial  frictions 
and  lar,<Tje  doses  of  the  iodides. 

2.  Syphilis  and  General  Paralysis. — Here  we 
encounter  the  most  important  part  of  the  question  of 
the  relations  of  syphilis  and  mental  alienation.  Two 
points  require  consideration:  (1)  Is  syphilis  a  cause 
of  general  paralysis  ?  (2)  Does  syphilis  give  rise  to 
cerebral  conditions  resembling  general  paralysis  but 
not  identical  with  it,  in  other  words,  does  it  produce 
a  pseudo-general  paralysis  ? 

The  first  of  these  may  be  left  for  the  present  as  it 
can  be  better  discussed  in  connection  with  the  causes 
of  general  paralysis,  and  we  will  confine  ourselves  to 
sajdng  that,  in  spite  of  the  persistence  of  a  certain 
amount  of  difference  of  opinion  as  to  this  point, 
syphilis  tends,  at  the  present  time,  to  take  a  more 
and  more  important  place  in  the  etiology  of  general 
paralysis. 


392         I2?-SAinTIES  WITH  GENERAL  DISOBDEES. 

Syphilitic  Pseudo- General  Paralysis. — If  there 
is  yet  far  from  being  general  accord  as  to  the  part 
that  syphilis  plaj^s  as  regards  genuine  general  paraly- 
sis, there  is  nearly  a  unanimity  in  the  admission  that  it 
may  produce  morbid  conditions  closely  resembling 
that  disorder.  Even  those  who,  like  M.  Magnan, 
reject  the  theory  of  pseudo-general  paralysis,  recog- 
nize fully  that  certain  infections,  such  as  syphilis,  or 
certain  intoxications,  such  as  alcoholism,  are  capable 
of  producing  symptom  complexes  more  or  less  similar 
to  that  of  the  malady  of  Bayle,  but  that  that  is  no 
good  reason  they  claim  for  the  creation  of  the  term 
"pseudo-general  paralysis."  It  is  the  word,  there- 
fore, rather  than  the  thing  that  is  objected  to,  and 
as  the  term  is  convenient  and  has  already  passed 
into  current  scientific  language,  it  seems  worth  while 
to  retain  it. 

The  expression  "syphilitic  pseudo-general  par- 
alysis" was  proposed  in  1879  by  Professor  Fournier, 
but  the  morbid  entity  had  been  previously  known. 
Ah'eady  in  1862  Zambaco  remarked  that  "syphilis of 
the  brain  may  cause  a  general  paralysis  of  movement 
with  also  mental  alienation,  the  paralysis  resembling 
and  liable  to  be  mistaken  for  paralytic  insanity." 
Later,  in  1873,  Lancereaux  said  in  his  turn :  "Certain 
syphilitic  lesions  of  the  brain  may  give  rise  to  a 
symptomatic  total  having  a  great  resemblance  to  the 
morbid  conditions  known  under  the  names  of  general 
paralysis  and  paralytic  dementia."  Finally  in  1877, 
Julius    Mickle,    in     an    important   article    entitled 


CHEONIC  INFECTIOUS  DISEASES.  393 

"  Syphilis  and  Insanity,"  affirmed  that  cerebral  sy]^)h- 
ilis  and  general  paralysis  are  two  distinct  disorders, 
as  is  proven  by  pathological  anatomy,  but  that  the 
difference  is  still  more  important  in  a  clinical  point 
of  view.  He  described,  in  particular,  as  distinctive 
features  of  cerebral  syphilis  in  its  mental  foiins :  the 
habitual  existence  of  hj^pochondriacal  ideas  in  the 
beginning  and  the  rarity  of  exalted  delusions;  less 
pronounced  dementia;  absence  of  labial  and  facial 
tremor,  and  slight  degree  of  its  appearance  in  the 
tongue  when  it  existed;  more  paralytic  than  ataxic 
character  of  the  embarrassment  of  speech ;  obstinacy 
of  nocturnal  headache ;  frequency  of  ocular  paralysis 
with  the  inequality  of  the  pupils  (double  optic 
neuritis,  atrophy  of  papillae,  choroiditis,  blindness, 
strabismus,  ptosis)  and  also  of  unilateral  or  localized 
paresis ;  physical  cachexia  often  very  marked ;  irreg- 
ularity of  evolution.  In  his  interesting  Treatise  on 
General  Paralysis  of  the  Insane,  (2d  edition,  Lou- 
don, 1886),  Mickle  reproduced  and  developed  the 
characters  of  the  differential  diagnosis. 

It  was,  however,  the  distinguished  j^rofessor  of 
the  Saint  Louis  who,  in  elucidating  syphilitic  pseudo- 
general  paralj^sis  and  in  seeking  to  differentiate  it 
from  true  general  paralysis,  has  called  attention  to 
this  question.  According  to  him  the  principal  points 
of  difference  are  the  following :  nearly  always,  if  not 
invariably,  the  delirium  in  syphilis  is  absolutely  free 
from  the  ambitious  wanderings  proper  to  general 
paralysis;  tremor  is  less  common,  especially  of  the 


394  INSANITIES  WITH  GENERAL  DISOEDEES. 

tongue  and  upper  lip,  and  is  also  less  delicate ;  the 
motor  disorders  of  a  j^aralytic  nature  (hemiplegia, 
monoplegia,  facial  hemiplegia,  ocular  paralysis)  are 
more  frequent  and  more  marked;  the  apoplectic 
strokes  and  sudden  paralyses,  attesting  a  localized 
lesion,  often  commence  the  trouble,  while  contrary 
to  the  nile  in  general  paralysis,  the  mental  troubles 
only  appear  later;  the  alteration  of  the  general 
condition,  sometimes  very  precocious,  with  emacia- 
tion, cachexia,  peculiar  facies  (syphilitic  appearance), 
is  more  special  to  pseudo-general  paralysis ;  the  lat- 
ter,  moreover,  has  a  less  regular  and  methodic  evolu- 
tion ;  its  progress  is  irregular ;  its  symptomatic  mani- 
festations and  their  succession,  are  more  variable; 
it  is  impossible  to  determine  its  duration  even  approx- 
imately ;  finally,  its  cure  is  not  usual  or  frequent,  but 
is  possible.* 

The  anatomical  lesions  are  also  different  in  the 
two  disorders,  and  their  difference  consists  especially 
in  the  fact  that  in  syphilitic  pseudo-general  paralysis, 
the  alterations,  instead  of  predominating  in  the  gray 
substance,  occupy  essentially  the  meninges  which  be- 
come adherent,  through  adhesive  inflammation,  to 
the  brain  (meningo-cercbral  symphysis,  hyperplasic 
meningitis,  meningeal  sclerosis). 

Since   then    otliei"  authors   have  insisted  on    the 

*In  a  more  recent  paper  (Ann.  de  PsycJi'uitrie  et  d'Hi/pnolo^ie, 
1893),  Fournier  apparently  abandons  his  old  views  as  to  pseudo- 
pjeneral  paralysis.  He  says,  in  effect,  that  what  he  used  to  call  syph- 
ilitic pseudo-paresis  he  now  considers  more  correctly,  at  least  inmost 
cases,  as  genuine  paretic  dementia.— Translatoe. 


CHEOXIC  IXPECTIOTJS  DISEASES.  395 

differential  diagnosis  of  general  paralysis  and  the 
syphilitic  psendo-paral3'sis,  notably  Savage  and  Hurd 
(Congress  in  Washington,  1887)  and  Motet  (in  Morel- 
Lav  allce  et  BoUeres  1889).  They  have  only  con- 
firmed the  distinctive  characters  indicated,  and  nota- 
bly the  irregularity  of  its  course  and  the  possible 
curabilit}''  of  syphilitic  paralysis. 

It  follows  from  these  data  that  the  majority  of 
authorities  admit  under  one  form  or  another,  a  spe- 
cific pseudo-general  paralysis,  separated  from,  true 
general  paralysis  especially  by  clinical  differences, 
which  can  be  summed  up  as  follows :  dementia  less 
pronounced ;  habitual  melancholic  delirium ;  delusions 
of  grandeur  less  frequent,  more  coherent;  less  embar- 
rassment of  speech,  rather  paralytic  than  ataxic; 
tremor  of  lip  and  tongue  often  absent ;  motor  disturb- 
ance of  paralytic  order  more  frequent;  course  more 
irregular;  duration  longer;  recovery  possible.  If 
we  except  the  particular  features  relative  to  the 
course  of  the  disease,  its  duration  and  termination, 
which  are  pathognomonic,  we  do  not  believe  that 
there  exist  any  very  evident  differences  between  the 
two  conditions  as  regards  morbid  phenomena.  In 
any  case,  the  differences  are  neither  constant  nor 
important  enough  to  legitimize  such  a  purely  symp- 
tomatic differential  diagnosis  as  has  been  attempted, 
and  in  this  matter  we  agree  with  the  lamented  A. 
Foville,  who  thought  that  the  term  syphilitic  pseudo- 
general  paralysis  should  be  reserved  for  cases  where 
different  lesions  have  given  rise  to  sympt6ms  liko 


396       nrsA^'iTiEs  with  general  disorders. 

true  paresis.  To  be  able  to  say  "pseudo-general 
paralysis  "  there  ouglit  in  fact  to  be  similar  symptoms, 
at  least  the  essential  ones  should  be  the  same ;  and 
lacking  this  the  term  pseudo-paralysis  has  no  further 
raisoih  cVetre. 

Without  troubling  one's  self  with  more  or  less 
problematical  shades  of  difference  between  the  symp- 
toms of  the  two  disorders,  the  designation  sj'philitic 
pseudo-general  parah'sis  may  therefore  be  reserved 
for  those  specific  cerebropathies,  which,  while  clinic- 
ally similar  to  general  paralysis,  differ  absolutely 
from  it  as  regards  their  course  and  prognosis,  and 
consequently  in  their  lesions.  True  paresis  has  a 
progressive  course,  a  fatal  prognosis,  and  incurable 
lesions.  The  pseudo-paresis,  whether  it  be  infec- 
tious as  when  from  syphilis,  or  toxic  as  in  alcoholism, 
has  a  regressive  course,  a  relatively  favorable  prog- 
nosis, and  curable  lesions.  Whenever  this  triple 
condition  of  regressive  course,  favorable  prognosis, 
and  curable  lesions  is  realized  in  a  morbid  condition 
similar  in  symptoms  to  general  jDaralysis,  we  may 
apply  to  it  the  name  of  pseudo-paresis.  It  is  thus 
we  understand,  for  ourselves,  the  pseudo-general 
paralysis  in  general  and  that  from  syphilis  in  partic- 
ular. Although  the  term  pseudo-general  paralysis 
itself  is  unacceptable,  nothing  is  more  easy  than  to 
consider  these  conditions  as  general  paralysis,  but  as 
special  forms  to  which  may  be  applied  the  adjective 
regressive^  in  opposition  to  genuine  general  paralysis 
which  is  essentially  progressive. 


DIATHESES.  397 

However  it  may  be  considered,  syphilitic  pseudo- 
general  paralysis  may  present  itself  under  any  form, 
demented,  depressive  or  expansive.  The  character- 
istic peculiarity,  whatever  may  be  their  form,  is  that 
the  symptoms  rapidly  attain  their  greatest  intensity, 
and  that  sometimes  the  patients  are  demented  and 
filthy  from  the  very  beginning.  Then,  after  a  cer- 
tain time,  especially  if  under  sj^eciiic  treatment,  the 
symptoms  are  observed  to  improve  by  degrees,  and 
there  occurs  an  evident  amelioration  or  even  a  gen- 
uine recovery  takes  place.  When  we  see,  therefore, 
in  a  syphilitic  subject  with  or  without  a  prodromic 
apoplectic  attack,  a  very  rapidly  appearing  and  pro- 
found dementia  with  paresis,  accompanied  or  not  by 
delusions,  we  should  be  on  our  guard  for  a  syphilitic 
pseudo-paresis,  and  institute  at  once  an  appropriate 
course  of  treatment  which  will  often  be  successful. 
As  to  the  lesions  of  syphilitic  pseudo-paresis,  they 
cannot  always  be  determined  on  account  of  the  rela- 
tive curability  of  the  disorder,  but  from  this  fact 
that  they  are  not  irremediable,  we  may  assume  that 
they  are  usually  neoplasms  of  rapid  evohition,  acting 
by  compression  on  the  mass  of  the  brain. 

§  11.     DIATHESES. 
(Diathetic  Insanities). 

The  scientific  conception  of  the  v/ or d  d lat/ies is  has 
been  considerably  modified  of  late  years,  and  its  sig- 
nification has  been  made  more  precise  at  the  same 


398  INSAZ^TIES  WITH  GEXERAL  DISOEDEES. 

time  that  it  has  been  limited  under  the  influence  of 
some  notable  memoirs,  in  the  first  rank  of  which  we 
may  place  those  of  M.  Oh.  Bouchard. 

Bouchard  defines  diathesis  as:  "a  permanent  dis- 
turbance of  the  nutritional  changes  that  prepares, 
provokes,  and  maintains  various  diseases  as  to  their 
symptomatic  forms,  their  anatomical  locations,  and 
their  pathological  processes.  The  commion  bond  of 
these  different  disorders,  but  of  the  same  family,  the 
common  cause  that  engenders  and  associates  them, 
is  the  general  disturbance  of  nutrition,  it  is  the  dia- 
thesis characterized  by  obstructed  nutrition.  A  dia- 
thesis is  a  morbid  temperament." 

I  will  speak  here  only  of  the  intellectual  disorders 
connected  with  artliritism  in  general  and  with  its 
principal  manifestations  ( rheumatism,  gout,  dia- 
betes), and  those  rarer  ones  associated  with  cancer. 
I  have  used  to  advantage  in  the  preparation  of  this 
part  of  the  chapter  the  masterly  article  of  Pro- 
fessors Lemoine  and  Pluyghes  '"''VArthritisme  dans 
ses  rapports  avec  le  JVervosisme.''^  [Gaz.  MCd.  de 
Paris,  February,  March  and  April,  1891),  and  also 
the  yet  unpublished  memoir  of  MM.  Mabille  and 
Lallement  on  "ies  Folies  diathesiques,''^  recently 
crowned  by  the  Academy  of  Medicine,  and  which, 
thanks  to  the  kindness  of  the  authors,  I  have  been 
able  to  consult. 

Atithritism. 

Arthritism  is  a  general  vice  of  the  organism  char- 
acterized by  retardation  of  the  nutrition  (Bouchard) , 


DIATHESES.  399 

*'It  is  made  np  of  a  host  of  manifestations  that  all 
appertain  to  an  arthiitico-nervous  cycle  in  which 
we  find,  side  by  side,  migraine,  epilepsy,  gout,  hys- 
teria, rheumatism,  diabetes,  etc.  It  also.^  includes 
precocious  atheromasia,  and  the  arterites  with  angina 
pectoris,  all  due  to  inflammations  of  special  characters 
and  locations."    (Pierret). 

Arthritism  is  especially  characterized  by  a  ten- 
dency to  congestions  (diathhe  congestif  of  Cazalis 
and  Senac).  By  reason  of  these  frequent  congestions 
or  on  account  of  some  yet  unknown  general  cause, 
the  general  nutrition  is  profoundly  altered.  The  or- 
ganic combustions  are  imperfect,  whence  the  passage 
frequently  into  the  blood  of  acid  substances,  such 
as  uric  acid  in  gout,  lactic  acid  in  rheumatism, 
which  act  on  the  economy  as  toxic  foreign  bodies. 

Thus  is  brought  about  in  the  end  a  sclerotic  pro- 
cess, first  vascular,  then  parenchymatous,  acting  on 
this  or  that  organ  according  to  its  degree  of  re- 
sistance. 

On  the  other  hand  arthritic  subjects  are  very  often 
dyspeptic;  many  of  them  have  dilatations  of  the 
stomach  and  disorder  of  the  intestinal  functions. 
This  is  a  source  of  toxic  action,  by  way  of  auto- 
intoxication, to  which  should  be  added  that  result- 
ing from  the  non-retention  in  the  sclerosed  liver,  of 
certain  physiological  poisons. 

It  is  in  the  frequency  of  the  congestive  rushes  of 
blood  to  the  head  and  in  the  intensity  of  this  double 
auto-intoxication   that  the   origin   of   the    nervous 


400  rS'SAXITIES  TFITH  GEXEEAL  DISORDEKS. 

troubles  so  common  in  the  subjects  of  arthritis  is  to 
be  sought. 

I  will  say  a  word  first  on  the  mental  condition  in 
arthritism  in  general,  and  then  on  the  special  intel- 
lectual disorders  of  rheumatism,  gout,  and  diabetes. 

1. — Arthkitism  in  General. 

Arthritic  subjects  most  frequently  present  a  spe- 
cial character.  According  to  M.  Lemoine,  that  which 
predominates  in  them  is  a  restlessness  that  shows  it- 
self by  mobility,  desire  to  move  or  change  places,  a 
great  psychic  sensibility  with  indecision,  anxiety 
and  sadness,  a  tendency  to  hypochondria  that  may 
show  itself  here  either  under  the  nosophobic  form 
(worry  as  to  health,  imaginary  ailments),  or  in  the 
so-called  moral  form  (discouragement,  pessimism, 
lack  of  object  in  life,  etc.) 

Together  with  these,  so  to  speak,  distinctive  marks 
of  the  arthritic  character,  should  be  noted  the  men- 
tal instability,  the  excessive  action  of  objects  or  cir- 
cumstances on  the  humor  of  the  moment,  finally  also 
the  modifications  of  the  mental  state  under  the 
influence  of  the  times,  the  temj)erature,  the  seasons, 
etc. 

Arthritic  patients  are  sometimes  subject  to  illusions, 
generally  visual,  consisting  in  the  transformation  of 
shadows  into  animated  and  moving  objects,  such  as 
mice,  cats,  dogs,  etc.  These  fugitive  and  temporary 
illusions,  seem  to  have  relation  with  the  disorders  of 
the  cerebral  circulation  and  coincide  with  the  fits  of 


DIATHESES.  401 

hyiDochondria.  M.  Lemoine  compares  them  to  the 
ocular  symptoms  of  migraine  (scintillant  scotomata, 
hemiopia,  muscae  volitantes) ,  with  this  difference  that 
the  latter  are  purely  sensorial  phenomena  and  not 
psycho-sensorial. 

The  need  of  air  and  space  felt  by  these  patients 
produces  in  them  the  sense  of  oppression  and  want  of 
breath  under  certain  circumstances,  such  for  example 
as  being  in  a  church,  in  halls,  in  closed  chambers, 
in  crowds,  in  the  dark,  in  water,  etc.  This  anxiety, 
at  once  bodily  and  mental,  reaches  in  certain  cases 
the  proportions  of  claustrophobia. 

The  sleep  in  these  patients  is  usually  unquiet, 
peopled  with  unpleasant  dreams,  making  a  strong  im- 
pression and  vividly  remembered,  sometimes  repeated 
more  oi*  less  periodically,  and  having  for  their  starting 
point  organic  sensations.  Or  again  there  is  only  a 
semi-slumber  with  vague  apprehensions,  startings, 
cramps,  involuntary  contractures.  At  certain  times 
actual  attacks  of  insomnia  appear. 

The  mental  troubles  of  arthritic  subjects,  what- 
ever they  may  be,  are  essentially  mobile  and  par- 
oxystic  and  subject  to  the  fluctuations  of  the  bodily 
condition.  They  may  be  aggravated,  or  on  the 
other  hand  relieved,  and  even  made  to  disappear 
under  the  influence  of  various  derivations,  such  as 
hajmorrhoidal  or  menstrual  flux,  attacks  of  diarrhoea, 
polyuria,  glycosuria,  hjqjerhydrosis,  attacks  of  mi- 
graine or  asthma,  eruptions  of  cutaneous  exanthe- 
mata or  articular  fluxions,  etc. 


402         INSANITIES  WITH  GENEEAL  DISOBDEES. 

There  is  often  observed  a  very  well-marked  equili- 
brium between  the  psychic  accidents  and  the  other 
diathetic  manifestations,  and  this  law  applies  not 
only  to  the  simple  modifications  of  the  mental  and 
moral  condition  but  also,  and  particularly  to  the 
more  serious  neurotic  or  vesanic  accidents,  that 
have  heretofore  been  called  for  this  reason  herpetic, 
dartrous,  migrainous,  hemorrhoidal,  asthmatic,  etc., 
insanities. 

Among  the  neuroses  related  to  arthritism  one  of 
the  most  frequent  is  undeniably  neurasthenia.  Some 
authorities,  such  as  Axenfeld  and  Huchard,  consider 
this  affection  as  developing  itself  by  preference  on 
an  arthritic  basis,  and  M.  Lemoine  goes  still  farther 
and  does  not  hesitate  to  declare  that,  in  most  cases, 
neurasthenia  is  an  arthritic  neurosis.  This  is  also 
the  opinion  of  M.  Bordaries  (Thes.  de  Bordeaux, 
1890).  This  pathogenic  conce])tion  seems  the  more 
probable,  since  the  arthritic  subject  is,  as  we  have 
seen,  before  all  unquiet  and  anxious,  so  that  he  bears 
with  him  in  the  germinal  condition,  in  a  mental 
point  of  view,  the  elements  of  neurasthenic  emotivity. 

The  symptoms  and  varieties  of  neurasthenia,  to 
which  a  special  chapter  has  already  been  devoted, 
need  not  be  described  again  here.  It  may  merely 
be  stated  that  in  arthritis,  the  neurosis  is  observed 
in  all  its  forms,  visceral  or  cerebral,  and  that  gener- 
ally it  appears  in  its  simple  form  and  at  every  stage, 
without  any  complication  of  degeneracy. 

Hysteria  (Huchard,  Charcot),  chorea  (rheumatis- 


DIATHESES.  403 

mal  chorea),  epilepsy  (B.  Teissier),  angina  pectoris 
(Laudouzy),  paralysis  agitans  (Pieriet,  Vaisselle), 
may  likewise  have  arthritism  for  their  originating 
cause. 

The  same  is  true  of  insanity,  properly  speaking. 
We  have  generally  in  this  event,  as  has  been  shown 
by  Rouillard,  Mabille  and  Lallement,  Lemoine  and 
Huyghes,  intermittent  and  sometimes  periodic  at- 
tacks of  melancholia,  especially  melancholia  with 
consciousness,  characterized  by  physical  and  -mental 
torpor,  inquietude,  fixed  ideas  of  hypochondria  and 
discouragement,  tendency  to  suicide  and  gastro-in- 
testinal  disorders,  together  with  more  or  less  pro- 
nounced stigmata  of  neurasthenia  (cephalalgia,  rachi- 
algia,  weakness  of  the  limbs,  genital  impotence, 
spells  of  obsession,  local  perspirations,  etc.,  etc.), 
which  frequently  give  to  the  disorder  the  aspect  of  a 
neurosis  rather  than  a  vesania.  We  may  also  encoun- 
ter, I  believe,  maniacal  excitation  or  double  form 
insanity.  These  outbreaks  of  insanity  are  accompan- 
ied by  local  congestive  attacks,  or,  on  the  other 
hand,  alternate  with  them.  Mabille  and  Lallement 
lay  much  stress  on  the  intermittent  and  periodic 
character  of  the  mental  disturbances  in  artliritism, 
which  are,  according  to  them,  characteristic  signs, 
to  the  extent  that  they  advise  the  search  for  the  ex- 
istence of  the  diathesis  in  the  ancestry  and  in  tiie  in- 
dividual antecedents  of  every  case  of  insanity  and 
in  melancholia  occurring  in  attacks  in  particular. 
The  memoirs  of  MM.  Mabille  and  Lallement  seem 


404         rN-SANITIES  WITH  GENERAL  DISOEDERS. 

to  demonstrate,  moreover,  and  this  is  a  point  of 
mucli  interest,  that  the  attacks  of  insanity  in  arthritic 
cases  coincide  with  the  chemical  changes  of  the  or- 
ganism, notably  with  hypoazoturia,  hypophospha- 
tiiria,  oxaluria,  with  marked  variations  in  the  amount 
of  urea,  and  particularly  with  actual  discharges  of 
uric  acid  which  a^enerallv  announce  the  end  of  the 
attack.  The  experiments  of  the  same  authors  on 
the  comparative  toxicity  of  the  urine  during  the  at- 
tack and  in  the  intervals,  have  broached  the  invest- 
igation but  have  not  given  any  positive  results. 
They  show  nevertheless  that  at  certain  times  this 
toxicity  falls  below  the  normal  which  seems  to  in- 
dicate that  there  is  at  such  periods  a  retention  of 
toxic  products  in  the  organism. 

As  to  general  paralysis,  it  seems  to  have  direct 
relations  with  arthritism.  Many  authorities  have 
already  pointed  out  the  frequency  of  heredity  of 
congestive  tendencies  in  chronic  meningo-encej^h- 
alitis  (Lunier,  Doutrebente,  Baillarger,  Ball  and 
Regis,,  etc.),  and  others  have  called  attention  to  the 
existence  in  paretics  of  some  of  the  stigmata  of 
arthritism  such  as  hemorrhoids,  migraine,  exanthe- 
mata, diabetes,  articular  inflammations,  local  sweats, 
etc.  (Charcot,  Cliarpentier,  Lemoine).  I  have  my- 
self described  a  curious  case  of  retraction  of  the 
palmar  aponeurosis  (Dupuytren's  disease)  in  a  gen- 
eral paralytic  suffering  from  hereditary  arthritis. 

There  are  evidently,  therefore,  frequent  relations 
between   arthritism  and  progressive  general  paral- 


DIATHESES.  405 

ysis.  The  nature  of  these  relations  is  yet  far  from 
clear,  and  we  can  only  notice  as  to  this  point  the 
opinion  of  M.  Lemoine,  according  to  which  arthrit- 
ism  is  the  predisposing  cause  of  paresis,  for  which  it 
prepares  tlie  Avay,  by  its  repeated  congestions  and 
its  over-production  of  the  products  of  disassimila- 
tion,  for  its  later  development  by  an  exciting  cause, 
such  as  intoxication  (alcoholism,  saturnism)  or  infec- 
tion (syphilis,  malaria). 

The  diagnosis  of  the  psychic  disorders  connected 
with  arthritism  generally  presents  no  difiiculties. 
We  should  remem})er  merely  that  in  the  majority 
of  cases  of  emotional  neurasthenia  and  of  intermittent 
insanity,  especially  of  reasoning  melancholia,  we 
should  suspect  this  diathesis  and  look  up  the  family 
history  and  the  stigmata  of  the  patient  without  neg- 
lecting the  very  valuable  data  furnished  by  the  full 
and  frequent  analysis  of  the  urine. 

The  prognosis  of  alienation  of  arthritic  origin,  ex- 
cepting always  general  paralysis,  is  not  grave, 
properly  speaking,  and  the  recovery  is  the  rule. 
We  ought  not,  however,  to  forget  that  the  charac- 
teristic of  the  diathetic  manifestations,  mental  or 
physical,  is  intermittence,  and  that  we  find  ourselves 
often  in  the  presence  of  an  apparenth''  curable  in- 
sanity but  one  that  is  really  hopeless  on  account  of 
the  inevitable  return  of  the  attacks. 

The  treatment  should  be  addressed  first  of  all  to 
the  diathesis.  The  general  condition  of  the  patient 
and  his  organic  functions,  especially  the  gastro-in- 


406  DfSAlflTIES  WITH  GE^'EEAL  DISOEDEES. 

testinal  and  hepatic  and  circnlatory  functions;  the 
composition  of  the  blood  and  perspiration,  and  more 
especially  of  the  urine;  the  appearance  or  disappear- 
ance of  habitual  hasmorrhages  (heemorrhoids) ,  of  ex- 
anthemata, of  asthmatic  attacks,  and  of  migraine, 
all  form  so  many  precious  indications  for  the  treat- 
ment. I  have  many  times,  since  the  pathogeny  of 
the  arthritic  psychosis  has  been  determined,  been 
able  to  rapidly  and  appreciabh^  ameliorate  their 
symptoms  by  the  use  of  large  doses  of  the  alkalines, 
salicylates  and  lithates,  antiseptics,  repeated  pur- 
gations, lavage  of  the  stomach,  etc.,  and  at  the 
present  time  I  am  attempting,  in  an  obstinate  and 
hereditary  case  of  arthritism,  to  break  up  the  peri- 
odicity, heretofore  regular,  of  attacks  of  mania  fol- 
lowed by  depression,  i.e.,  a  biennial  attack  of  double 
form  insanity,  by  a  preventive  anti-arthritic  treat- 
ment. 

2.  — Rheumatism. 

{Wieumatismal  Insanity). 

It  is  a  well  known  fact  that  articular  rheumatism, 
in  its  acute  manifestations,  may  give  rise  to  mcnin- 
gitic  or  apoplectic  complications  that  have  received 
the  name  of  cerebral  rheumatism.  These  accidents 
may,  in  their  turn,  be  accompanied  by  delirious  dis- 
turbances, showing  themselves  usually  in  the  acute 
or  hyperacute  form,  with  incoherence,  loquacity, 
great  excitement,  etc.  This,  however,  is  not,  prop- 
erly speaking,  a  vesania ;  it  is  only  a  febrile  delirium 
pushed  to  an  excessive  degree. 


DIATHESES.  407 

The  vesanic  disorders  of  rheumatisiu ,  those  that 
form  what  we  may  call  rheumatismal  insanity,  are 
of  two  orders.  They  may  occur  in  chronic  rheuma- 
tism, independently  of  the  acute  attacks  of  the  dis- 
ease ;  or  they  may  be  intimately  connected  with  these 
latter. 

First  described  by  Leuret  in  1845,  they  have 
since  then  been  the  subject  of  special  studies  by 
Mesnet,  Griesinger,  Morel,  Fleming,  Fraser,  Simson, 
Simon,  Marechal,  Ball  and  Faure,  etc. 

The  mental  troubles  allied  to  chronic  rheumatism, 
consisting  usually  in  modifications  of  character,  fall 
into  the  class  already  described  under  the  name  of 
the  mental  state  of  arthritism.  There  is  therefore 
no  necessity  of  redescribing  them  here. 

The  true  rheumatismal  insanity  is  that  occurring  in 
connection  with  the  acute  attacks  of  the  disease. 
Its  outbreak  generally  occurs  during  convalescence ; 
sometimes  also  it  occurs  during  the  attack  itself, 
and  in  this  case  it  commonly  replaces  the  articular 
symptoms  which  may  re-appear  again  at  its  disappear- 
ance. Almost  always  it  takes  on  the  melancholic 
form,  especially  when  it  occurs  during  convales- 
cence. Only  when  its  onset  is  during  the  attack 
itself  docs  it  appear  under  the  form  of  acute  mania. 

All  varieties  of  melancholia  may  be  met  with  in 
rheumatism,  from  simple  melancholic  depression  to 
complete  stupor.  Commonl}^  there  is  a  more  or  less 
pronounced  torpor,  with  characteristic  delusions  and 
hallucinations.     The  patients  have  terrific  visions; 


408  rxSAXITIES  WITH  GENEEAL  DISORDEES. 

they  see  every  thing  in  flames  (Mesnet) ;  they  are 
pursued  by  ferocious  beasts  (Vaillard) ;  they  see 
worms  crawling  on  their  beds  (Burrows) ;  they  think 
themselves  to  be  dead.  The  less  frequent  auditory 
hallucinations  are  of  the  same  nature  and  usually 
consist  in  curses  and  insults.  There  is  generally  also 
sitiopliobia,  tendency  to  suicide,  and  sometimes 
sudden  and  violent  impulsions.  This  state  is  there- 
fore, as  we  see,  not  without  analogy  with  alcoholic 
insanity,  which  fact  seems  to  support  tbe  newer 
theory  that  makes  rheumatismal  manifestations  the 
result  of  a  veritable  auto-intoxication. 

Wbatever  ma}^  be  the  form  of  the  insanity,  the 
basis  of  the  mental  condition  is  often  constituted  by 
a  greater  or  less  degree  of  intellectual  obtusion,  and 
occasionally  even  by  a  weakening  of  the  faculties 
that  may  become  permanent. 

Attacks  of  insanity  in  rheumatism  may  be  accom- 
panied with  c])oreiform  movements,  and  frequently 
coexist  with  cardiac  or  pericardial  disorders. 

Finally  they  may  alternate,  once  or  repeatedly, 
with  the  articular  attacks,  appearing  when  the  latter 
disappear,  and  vice  versa. 

Progxosis. — In  the  majority  of  cases,  about  three 
times  in  five,  recovery  takes  place.  Nevertheless  it 
is  rarely  complete,  as  there  very  commonly  remains 
a  certain  obnubilation  of  the  intelligence,  and  some- 
times even  decided  mental  weakness. 

Relapses  are  common  and  an  attack  of  insanity  in 


DIATHESES.  409 

the  course  of  an  attack  of  rheumatism  predisposes  to 
others  under  similar  conditions. 

Death  rarelj  occurs  and  is  hardly  ever  due  to  the 
insanity,  but  rather  to  the  rheumatism  or  its  compli- 
cations or  the  general   condition  accompanying  it. 

Like  simple  mania  and  melancholia,  rheumatismal 
insanity  is  not  attended  with  regular  and  invariable 
cerebral  lesions ;  generally  no  special  lesion  is  dis- 
covered and  only  the  usual  alterations  of  general- 
ized acute  insanity  are  met  with. 

The  treatment  offers  no  special  indications,  except 
perhaps  that  in  many  cases  there  may  be  some  ad- 
vantage in  reviving  the  articular  inflammation,  the 
return  of  which  occasionally  suffices  to  cause  the 
disappearance  of  the  mental  symptoms. 

3.— Gout. 

{Podagrous  Insanity), 

A  large  number  of  authors,  such  as  Sydenham, 
Todd,  Garrod,  Gairdner,  Lorry,  Clouston,  Besnier, 
Lecorche,  Sonac,  Ball,  Bouchard,  Charcot,  etc.,  have 
remarked  and  described  the  mental  disorders  that 
may  supervene  in  cases  of  gout.  These  are  the  same 
as  those  already  indicated  apropos  to  the  mental 
states  and  neurosis  of  arthritism.  The  insanity  of 
gout,  properly  so  called,  is  rather  rare  and  has  been 
little  discussed  up  to  the  present  time. 

The  greater  part  of  the  cases,  carefully  collected 
by  MM.  Mabille  and  Lallement,  belong  to  the  class 

Mekt.  ]\IiCD.— 26. 


410  IXSA]SnTIES  WITH  GENERAL  DISORDERS. 

of  attacks  of  insanity  occurring  during  the  gout  or, 
on  the  other  hand,  alternating  with  its  manifest- 
ations. 

"When  insanity  appears  during  a  gouty  attack  it 
is  nearly  always  in  the  form  of  acute  mania. 
When,  on  the  contrary,  the  insanity  alternates 
with  the  diathetic  symptoms,  it  usually  takes  the 
melancholic  form,  with  mental  and  physical  torpor, 
depression,  hebetude,  hypochondriacal  delusions,  and 
suicidal  tendency.  It  is  in  such  cases  that  we  see  a 
more  or  less  periodic  equilibrium  produced  between 
the  vesanic  and  the  podagrous  manifestations,  the 
dermatoses,  attacks  of  asthma,  etc. 

4. — DlAUETES. 

(Diabetic  Insanity). 

The  psychic  disorders  of  diabetes  have  been  espe- 
cially elucidated  by  Marchal  de  Calvi,  Legrand  du 
Saulle,  de  Santos,  Cotard,  Lecorche,  Fassy,  Mabille 
and  Lallement,  etc.  They  are  almost  always  lim- 
ited to  modifications,  more  or  less  profound,  of  the 
intelligence  and  feelings,  and  only  seldom  reach  the 
condition  of  confirmed  insanity. 

The  mental  state  of  diabetics  reveals  itself  in 
general  by  hypochondria,  torpor,  or  sometimes  invin- 
cible somnolence,  fears  of  ruin  or  misfortune,  mo- 
tiveless prepossessions,  and  tendency  to  suicide. 
The  hypochondria  here  necessarily  assumes  a  pecul- 
iar character ;  it  has  for  its  object  the  presence  of 


DIATHESES.  411 

sugar  in  the  urine,  and  impels  the  patient  to  examine 
it,  to  taste  it,  to  multiply  analyses,  and  to  discuss  the 
proportion  of  glucose  and  the  make-up  of  the  diet- 
ary regimen  to  the  exclusion  of  all  other  subjects. 
It  is  to  be  remarked  that  this  hypochondria  is  in 
direct  ratio  with  the  amount  of  sugar  excreted,  as  it 
improves  as  the  sugar  decreases.  Then  the  patients 
again  become  gay  and  lively,  confident,  less  solicitous 
about  themselves  and  more  open  to  outside  impres- 
sions. The  fears  of  ruin  have  the  effect  of  rendering 
the  patients  miserly,  parsimonious  to  excess,  possessed 
by  the  notion  of  inevitable  failure,  and  by  the 
desire  for  death  which  alone  can  save  them  from 
dishonor.  The  torpor  is  characterized  by  a  mental 
weariness,  a  fear  of  mental  effort,  "  the  loss  of  appe- 
tite for  thought  "(La segue).  A  characteristic  feat- 
ure of  the  mental  condition  of  diabetics  is  the  con- 
cordance of  the  changes  of  the  mental  condition 
with  those  of  the  sugar  in  the  organism,  and,  the  so 
to  speak,  barometric  influence  of  the  composition  of 
the  urine  on  the  mental  dispositions  and  emotions. 

Insanity,  properly  so-called,  is  rare,  as  was  said, 
in  diabetes.  When  it  occurs  it  is  habitually  in  the 
form  of  melancholia,  remittent  or  intermittent. 

In  general,  the  psychic  disturbances  of  diabetes 
appear  in  the  beginning  of  the  disorder.  Sometimes, 
nevertheless,  they  never  show  themselves  in  the  later 
stages.  In  some  cases  thej^  precede  the  glucosuria 
by  a  longer  or  shorter  period  and  they  may  then  be 
aggravated  by  its  appearance,  or,  on  the  other  hand, 


412  IXSAXITIES  -^VITH  GEXERAL  DISOEDEES. 

as  in  the  case  reported  by  Cotard,  they  may  disap- 
pear when  it  manifests  itself. 

5. — Cancek. 
{Cancerous  Insanity). 

It  is  known  that  cancer  has  affinities  that  tend 
to  become  more  and  more  Avell  established,  with  ar- 
thritism.  Bazin,  and,  more  recently,  Professor  Ver- 
neuil  have  made  themselves  the  defenders  of  this 
opinion.  Guislain,  Decorse,  Sauze  and  Aubanel,  Au- 
zony,  Dagonet,  Griesinger,  Trousseau,  Geoffroy  and 
Berthier  have  demonstrated  that  cases  of  insanity 
connected  with  a  cancerous  affection  are  rather  rare, 
if  we  except  cancers  of  the  brain,  Avhich  operate  by 
a  different  mechanism,  as  a  local  affection  and  not 
so  much  as  a  diathesis. 

The  forms  of  cancer  that  most  influence  the  de- 
velopment of  insanity  are  cancer  of  the  uterus  and 
cancer  of  the  stomach.  It  is  an  indubitable  fact 
that  it  is  the  cancer  which  in  the  majority  of  the 
patients  causes  change  of  character,  irritability,  de- 
pression, discouragement,  and  occasionally  also  ideas 
of  suicide.  It  is  only  in  predisposed  individuals  that 
an  actual  insanitj'^  supervenes. 

The  insanity  connected  with  cancer  is  nearly 
always  a  melancholia  with  hallucinations  and  hypo- 
chondriacal ideas  or  delusions  of  persecution.  As  in 
most  of  the  insanities  connected  with  visceral  dis- 
orders having  painful  and  morbid  sensations,  it  is 
notable  for  its  delusive  interpretations  of  actual  sen- 


DIATHESES.  413 

sations  that  we  call  internal  illusions.  The  female 
patients  claim  that  they  are  pregnant  or  have  been 
violated ;  they  have  frogs  or  serpents  in  their 
abdomens,  etc,  etc. 

Aside  from  this  peculiarity,  insanity  connected 
with  cancer  has  no  characteristic  symptoms  deserving 
of  notice. 

Its  diagnosis  may  often  present  some  difficulties 
as  it  resembles  in  all  points  true  melancholia,  and 
the  cancer  often  remains  latent  like  many  other  or- 
ganic affections  in  the  insane. 

As  regards  prognosis,  it  is  serious,  as  the  melan- 
cholic attack  is  never  really  acute ;  it  is  a  sub-acute 
type,  or,  rather,  an  attack  of  delusional  melancholic 
of  slow  and  progressive  course,  which  may  termin- 
ate in  dementia,  in  case  death  does  not  supervene 
from  the  progress  of  the  cancerous  cachexia. 


Cbaptet   firiF. 

IXSAXITIES  ASSOCIATED  WITH  DISEASES 
OF  THE  NERVOUS  SYSTEM. 

(Diseases  of  the  Brain.     Diseases  of  the  Spinal  Cobd. 

Neuroses). 


§1      INSANITIES    CONNECTED    WITH    DISEASES 
OF  THE   BRAIN. 

(Geneeal  Paralysis.    Apopleptic  Demextia). 

General  Paralysis  of  the  Insane. 

Definition. — General  paralysis  is  a  cerebral  dis- 
order, sometimes  cerebrospinal  (diffuse,  chronic, 
interstitial,  meningo-myelo-encephalitis)  essentially 
characterized  by  progressi^^e  sympAoms  of  dementia 
and  paralysis  (paralytic  dementia)  with  which  are 
frequently  associated  various  accessory  symptoms, 
and  especially  an  insatiity  of  the  maniacal,  melan- 
cholic, or  circular  type  (paralytic  insanity). 

Historical. — The  discovery  of  general  paralysis, 
of  which  Baillarger  was  able  to  say  with  reason 
that  it  was  the  greatest  step  in  advance  that  is  re- 
corded in  the  history  of  mental  disease,  dates  back 
not  more  than  sixty  years,  although  attempts  have 
been  made  to  show  that  it  was  earlier  recognized. 


GEKERAL  PARALYSIS  (HISTORICAL).  415 

and  more  particularly  that  Haslam  and  Perfect  had 
reported  cases  at  the  close  of  the  last  century. 

Esquirol  inaugurated  the  movement  by  noticing, 
in  a  general  way,  the  extreme  gravity  of  those  cases 
in  which  the  dementia  was  complicated  with  paral- 
ysis, and  the  evil  significance  that  should  be 
attributed  to  embarrassment  of  articulation  as  an 
element  of  prognosis. 

It  is  to  his  students,  however,  that  was  reserved 
the  honor  of  actually  bringing  to  light  the  disease. 
Georget  described  it  in  1820  under  the  name  of 
chronic  muscular  paralysis;  Delaye,  in  1824  under 
that  of  incomplete  general  paralysis,  which  it  has 
since  retained;  Calmeil  finally,  in  1826,  under  that  of 
paralysis  observed  in  the  insane.  All  of  these  re- 
garded the  malady  as  a  special  form  of  paralysis 
superimposed  upon  the  insanity,  that  is,  as  the 
complication  of  an  already  existing  mental  disease. 

Bayle,  however,  had  already  in  1822,  in  his 
inaugural  thesis,  formulated  a  new  theory  and 
changed  the  condition  of  affairs.  According  to  him 
general  paralysis  is  not  a  mere  complication  of 
insanity,  but  is  a  true  morbid  entity.  He  desig- 
nated it  arachnitis  or  chronic  meningitis,  on  account 
of  its  predominant  lesion,  made  the  ambitious  delus- 
ions its  necessary  characteristic  sjmaptom,  assigned 
it  a  regular  course,  divided  into  three  sucessive 
periods ;  one  of  monomania,  another  of  mania,  the 
third  of  dementia.  Like  Calmeil  he  insisted  on 
its  anatomico-pathological    characters,  and    consid-/ 


416  INSANITY  WITH  DISEASES  OF  BEAIN. 

ered  pathognomonic  the  adhesions  existing  between 
the  meninges  and  the  convokitions. 

The  ideas  of  Bayle  were  accepted,  little  by  lit\,le, 
and  Parchappe  in  1838  went  so  far  as  to  regard 
general  paralysis  as  a  special  form  of  insanity, 
which  he  designated  under  the  name  of  paralytic 
insanity. 

Requin,  in  1846,  proposed  a  restriction  of  this 
view,  and  considering  that  general  paralysis,  to  which 
he  applied  the  epithet  progressive,  may  exist  without 
mental  symptoms,  he  recognized  two  forms :  the  one 
with  intellectual  disorders,  the  other  without  any 
disturbance  of  this  kind.  This  distinction  has  been 
confirmed  and  made  more  precise  by  a  number  of 
authors,  notably  by  MM.  Sandras,  Lunier,  and  Bail- 
larger.  The  latter  has  even  claimed  that,  in  a  psychic 
point  of  view,  it  is  the  dementia  and  not  delusions 
that  constitute  the  essential  symptom  of  the  disease. 
He  also  proposed  for  it  the  name  of  paralytic  de- 
mentia (1846). 

From  this  date,  investigations  multiplied  and  there 
aj)peared  a  series  of  important  memoirs  on  the  sub- 
ject, among  which  may  be  especially  cited  those  of 
Ch.  Lasegue,  J.  Falret,  and  A.  Linas. 

In  1858  there  took  place  in  the  Medico-Psychol- 
ogical Society  a  long  and  interesting  discussion 
which  resulted,  in  spite  of  the  objections  of  cer- 
tain opponents,  .notably  of  Baillarger  in  the  en- 
dorsement of  the  views  of  Bayle,  namely,  the  prin- 
ciple of  the  essentiality  of  general  paralysis.    From 


GENERAL  PARALYSIS  (HISTORICAL).  4l7 

that  time  to  the  present,  the  theory  of  general  paral- 
ysis has  not  been  brought  in  question. 

The  notion  of  a  morbid  entity  having  been  ac- 
cepted, attention  was  turned  more  particularly  to 
the  study  of  the  characteristics  of  the  disease. 

In  a  first  period,  filled  especialy  with  the  memoirs 
of  Baillarger,  the  clinical  analysis  of  the  disorder 
was  taken  up  and  its  description  perfected. 

In  a  second,  began  the  investigation  of  the  ana- 
tomo-pathological  lesions  and  the  application  to  it 
of  the  microscope.  It  is  no  longer  a  chronic  men- 
ingitis or  meningo-encephalitis  that  constitutes  the 
chief  alteration  of  the  disorder.  According  to  some 
it  is  a  sclerosis  of  the  connective  tissue  of  the 
brain,  others  consider  it  a  degenerative  lesion  of  the 
great  sympathetic,  and  finally,  by  certain  individ- 
uals, it  is  held  to  be  a  myelitis  rather  than  an  en- 
cejDhalitis. 

Next  the  attention  is  called  anew  to  the  altera- 
tions of  the  meninges  and  the  cortical  layers.  The 
theory  of  localizations  is  applied  to  the  study  of  the 
symptoms  of  paresis,  and  it  has  been  sought  to  find 
in  the  localizations  the  reason  of  the  symptomatic 
differences  of  the  malady  (Foville). 

Already,  however,  new  clinical  facts,  such  as  the 
remissions,  latent  general  paralysis,  general  paral- 
ysis of  double  form,  and  in  particular,  syphilitic, 
saturnine  and  alcoholic  pseudo-general  paralysis  had 
gradually  overthrown  the  unitary  theory  which  failed 
to  explain  them,  and  M.  J.  Falret  went  so  far  in 


4:18  IXSAXITY  WITH  DISEASES  OF  BEAIN. 

1877  as  to  say  that  the  history  of  general  paralysis 
must  be  rewritten. 

Thus  Baillarger  (18S2-3)  proposed,  with  good 
reason,  to  return  to  the  dualist  theory  upheld  by  him 
in  1858,  which  admits  the  existence  in  what  we  call 
general  paralysis,  of  two  quite  distinct  disorders,  sus- 
ceptible of  existing  associated  with  each  other  or 
separately :  (1)  paralytic  dementia,  the  principal  dis- 
ease ;   (2)  paralytic  insanity,  the  accessory  affection . 

This  dualist  theory,  upheld  unceasingly  by 
Baillarger  to  the  last  days  of  his  life,  counts  to- 
day numerous  partisans.  Some  alienists  even  tend 
at  the  present  time  to  consider  general  paralysis 
not  as  a  single  malady,  but  as  a  group  of  more  or 
less  distinct  diseases,  according  to  their  causes  or 
their  lesions,  "  as  a  genus  comprising  many  species" 
(Ball). 

At  this  point  ends  the  history  of  general  paralysis. 
E)i  resume  when  Ave  glance  over  the  whole  scientific 
evolution  of  this  disease  we  note  that  it  has  passed 
through  three  principal  stages:  (1)  in  the  first,  it  is 
considered  as  a  complication  of  insanity;  (2)  in  the 
second,  it  represents  a  morbid  unity  having  among 
its  other  symptoms,  insanity;  (3)  in  the  third, 
finally,  which  is  the  present  period,  it  tends  to  be 
considered,  if  not  as  a  group  of  cerebral  or  cerebro- 
spinal affections,  at  least  as  a  paralytic  dementia  to 
which  is  associated  more  or  less  frequently,  and 
under  various  conditions,  insanity. 

These  various  changes  of    opinion    and  differing 


GENERAL  PARALYSIS  (PARALTTIC  DEMENTIA).   419 

conceptions  of  general  paralysis,  have  had  their 
influence  on  the  progress  of  its  clinical  study,  which 
to-day  is  one  of  the  most  advanced  in  all  mental 
medicine. 

Description. — As  a  partisan,  with  M.  Baillargcr, 
of  the  dualist  theory  of  general  paralj^sis,  Avhich 
seems  to  me  to  best  correspond  with  the  facts,  I 
believe  that  the  disease  in  its  most  perfect,  un- 
complicated, and  essential  type  is  represented  clinic- 
ally not  by  this  or  that  delusional  form,  but,  on  the 
contrary,  by  general  paralysis  without  delusions,  by 
a  paralytic  dementia  essentially  made  up  of  a  de- 
mentia and  a  progressive  paralj'sis. 

Contrary  to  the  usual  practice,  therefore,  it  seems 
to  me  rational,  and  at  the  same  time  more  profitable 
to  the  study,  to  describe  first  the  type  of  the  disease, 
that  is  to  say,  the  paralytic  dementia.  Once 
acquainted  with  this  type,  we  can  next  examine  in 
the  sphere  of  insanity,  properly  so-called,  the  various 
phenomena  that  are  more  or  less  habitually  superadded 
to  the  paralytic  dementia  and  then-  different  modes 
of  association. 

Paralytic  Dementl\. 
(Prodomic  or  Preparalytic  Period). 

There  is  perhaps  no  disease  that  begins  more  grad- 
ually than  general  paralysis.  Except  when  it  begins 
with  a  congestive  ictus,  its  invasion  is  so  gradual 
and  insensible  that  it  is  almost  always  impossible  to 
fix  its  real  commencement  and  its  origin  is  lost,  so 


420         rN■sA^^TT  with  disea.ses  of  brain. 

to  speak,  in  the  darkness  of  the  past.  When  care- 
ful study  is  made  of  the  life  of  the  paretics  and  all 
data  obtained  from  their  families,  we  find  that  the 
first  changes  in  the  intellect,  the  feelings  and  the 
organic  functions  which  indicate  the  beginning  of 
the  disease,  date  back  many  years  before  its  apparent 
outbreak.  There  is  a  true  prodromal  period,  called 
the  pre-delirious  period  (Christian)  or  the  pre-paral- 
ytic  period  (Regis),  from  its  analogy  with  the  pre- 
ataxic  period  of  tabes. 

This  period,  of  which  only  a  few  symptoms  are 
known,  merits  a  special  study.  I  will  confine  myself 
to  the  brief  enumeration  of  the  principal  manifest- 
ations which  chiefly  are  of  a  bodily  and  organic 
nature. 

The  general  appearance  of  the  future  paretics  is 
often  modified  a  long  time  in  advance.  Their  ph3's- 
iognomy  is  changed,  they  have  a  dead  complexion, 
their  flesh  is  flaccid  and  pale,  their  features  drawn 
and  lacking  exj)ression,  the  hair  and  eyebrows  usually 
dr}^  and  thin,  their  eyes  moist  and  lacking  fire. 
Their  teeth  are  carious  and  incomplete  and  often 
fall  out  spontaneously  while  the  face  border  of  the 
gums  becomes  the  seat  of  a  quasi-scorbutic  ulceration. 

On  the  side  of  the  motility  and  sensibility  we  may 
meet  with:  sj^asms,  convulsions  (Jacksonian  ejDi- 
lepsy),  paralysis,  nearly  always  ocular  (strabismus, 
di^ilopia,  ptosis,  inequality  and  immobility  of  the 
pupils),  which  are  relatively  very  frequent  in  the 
years  preceding  the  attack  of  general  paralysis.    We 


GENERAL  PARALYSIS  (PARALTTIC  DEMENTIA).   421 

also  find  hypersesthesias  and  anaesthesias  of  the 
organs  of  sense  and  of  the  cutaneous  surface,  loss  of 
memory  of  localization  of  tactile  sensations  (Ziehen), 
various  derangements  of  the  reflexes,  especially  loss 
of  the  cremastic  reflex  with  testicular  insensibility 
and  atrophy.  Furthermore  it  is  not  uncommon  to 
observe  certain  nervous  disorders  such  as  cephalalgia, 
neuralgias,  ophthalmic  migraine  (Charcot),  gastric 
and  vesical  crises  analogous  to  those  of  tabes  (Hurd), 
symptoms  of  cerebral  or  spinal  neurasthenia,  of 
partial  epilepsy,  and  even  of  hysteria. 

Sleep  is  one  of  the  first  functions  to  be  disturbed 
and  it  is  rare  if  it  remains  altogether  intact.  It  is 
light,  and  unsatisfying,  disturbed  by  dreams  and 
nightmares,  cramps,  startings,  and  sometimes  by  epi- 
leptiform convulsions.  Very  frequently  the  respira- 
tion takes  on  a  special  type.  It  is  carried  on  by 
short  inspirations  that  hardly  raise  the  chest  walls  and 
that  are  cut  off  shortly,  followed  from  time  to  time 
by  long  and  plaintive  expirations.  This  is  a  charac- 
teristic mode  of  breathing  during  sleep  that  I  have 
met  many  times  in  general  paralysis  and  in  all  its 
stages. 

Another  hitherto  un described  sign,  that  from  its 
frequency  and  ease  of  observation  seems  to  merit 
special  mention,  is  the  condition  of  the  sternum  which 
by  a  slow  process  of  periostosis  finally  diminishes 
the  elasticity  of  the  thoracic  cage,  while  at  the  same 
time  the  xyphoid  appendix,  becoming  ossified,  is  de- 
pressed, elongated,  and  incurved  toward  the  abdo- 


422  IXSANITT  WITH  DISEASES  OF  BRAIN. 

men  in  such  a  way  as  sometimes  to  produce  severe 
pains.  In  some  cases  the  thorax  tends  to  become 
quite  immobile  and  respiration  consequently  becomes 
almost  exclusively  abdominal,  especially  during  sleep. 

The  alterations  as  regards  the  organic  and  trophic 
functions  are  not  less  frequent  and  numerous.  I  may 
mention :  capriciousness  of  the  appetite,  tendency  to 
dilatation  of  the  stomach  and  the  intestine,  gastric 
pain  and  vomiting  simulating  serious  disease  of  the 
organ,  habitual  constipation  alternating  with  colic 
and  sudden  attacks  of  diarrhoea,  palpitations  and 
feebleness  of  the  heart,  increased  sensibility  to  cold, 
vaso-motor  disturbances,  particularly  flushes  of  blood 
to  the  head,  trophic  disturbances  such  as  dystrophy 
and  spontaneous  shedding  of  the  nails,  malperforant^ 
arthralgias,  etc.,  alternating  exaggeration  and  sup- 
pression of  the  perspiration  or  of  periodical  fluxes, 
menstrual  or  hemorrhoidal,  more  or  less  transitory 
modifications  of  the  quantity  or  quality  of  the  urine 
(polyuria,  glycosuria,  peptonuria),  and  lastly  alter- 
ations in  various  ways  of  the  sexual  r)ower. 

Mentalh^  the  future  paretic  retains  all  the  appear- 
ances of  the  most  complete  intellectual  soundness. 
But  he  himself  realizes  that  his  mental  energy  is 
slowly  diminishing,  that  work  is  becoming  painful, 
that  he  has  failure  of  memory,  and  that  it  is  more 
and  more  by  a  sort  of  jDrofessional  automatism  that 
ho  accomplishes  approximately  well  his  daily  tasks. 
Some  observe  and  follow  anxiously  the  slow  process 
of  mental  and  physical  disorganization  that  is  going 


GENERAL  PARALYSIS  (PARALTTIC  DEMENTIA).   423 

on  in  themselves,  and  fully  conscious  of  their  condi- 
tion and  even  foreseeing  their  future,  they  may  at 
this  time  announce  their  future  general  paralysis  or 
seek  to  prevent  it  by  suicide.  Lastly,  the  character 
changes  little  by  little;  the  jDacients  become  moody, 
absorbed  in  their  condition;  they  are  readily  irri- 
tated, have  fits  of  passion,  changes  of  humor;  they 
are  unsettled  and  indifferent  to  everything.  Some- 
times they  have  true  spells  of  neuropathic  depres- 
sion, with  attacks  of  weeping;  or  rather,  they  be- 
come hypochondriacal,  and  complain  of  palpitations, 
of  suffocation,  of  all  kinds  of  evil  feelings ;  they  are 
anxious  to  consult  about  their  condition,  and  never 
cease  to  lament  it,  while  they  gorge  themselves 
with  drugs.  At  other  times  on  the  contrary,  they 
feel  active  and  vigorous  and  in  good  condition,  they 
have  an  abnormal  feeling  of  well-being  and  show  an 
extraordinary  ardor  for  work. 

Such,  taken  altogether,  is  the  list  of  signs 
observed,  either  wholly  or  in  j^art,  in  the  years  pre- 
ceding the  outbreak  of  general  paralysis.  Finalh'', 
however,  this  slow  incubation  is  completed  and  the 
invasion  of  the  malady  begins. 

There  have  been  already  manifested  some  signs 
of  mental,  moral  and  physical  failure,  forerunners 
of  the  coming  trouble.  ' '  The  attentive  observer, "  re- 
marks M.  J.  Falret,  "already  begins  to  notice  mo- 
mentary absences  of  memory  or  intelligence,  and 
true  lacuncB  in  the  conceptions,  in  a  word,  the  in- 
contestable traces  of  a  commencing  dementia,  Avhich 


424         rN-sAisT:TT  with  diseases  or  brain. 

are  the  characteristic  of  this  mental  disease,  even 
from  its  first  beginning." 

These  defects  may  be  summed  up  as  follows :  in- 
tellectuallj'-  there  are  strange  lapses  of  memory,  un- 
usual mistakes  in  spelling  or  calculations,  a  lack  of 
sequence  in  combinations  and  projects,  an  absolute 
inability  to  finish  anything,  etc.  Morally,  and  this 
is  most  striking  in  patients  of  the  higher  clases,  we 
see  a  very  noticeable  forgetfulness  of  the  rules  of 
politeness  and  decorum,  a  negligence  in  costume; 
sometimes  also  indelicacy  and  grossness,  and  finally, 
a  more  or  less  pronounced  tendency  to  alcoholism, 
to  a  cynical  erotism,  to  criminal  acts,  esi^ecially  ab- 
surd and  useless  theft.  Ph^^sically,  the  patient  be- 
comes awkward,  unskilful,  unfit  for  the  work  of  his 
trade ;  if  he  is  a  mechanic,  he  bungles  his  work,  be- 
gins it  again  only  to  do  it  worse,  and  loses  more  and 
more  his  aptitude  for  careful  and  accurate  move- 
ments, so  much  so  that  he  is  dissmisscd  by  his  em- 
ployers and  he  is  finally  unable  to  find  work.  At 
this  same  time  there  appear  some  slight  disturbances 
of  speech,  consisting  in  a  certain  hesitation,  espec- 
ially apparent  after  eating,  aud  sometimes  also  true 
congestive  attacks  of  the  apoplectiform  or  epilepti- 
form types. 

In  a  word  there  have  already  supervened  signs  of 
cnfeeblement  in  all  three  of  the  modalities  of  the  in- 
dividual, and  these  becoming  gradually  emphasized, 
attract  more  and  more  attention,  and  progressively 
conduct  the  patient  to  the  first  period  of  the  disease. 


GENEEAL  PAKAXTSIS  (fIEST  EEEIOD).  425 

First  Period. 

From  this  time  on  the  paralytic  dementia  is  estab- 
lished, and  it  is  characterized  from  the  first  by  two 
kinds  of  symptoms:  the  ones  physical,  the  others 
intellectual  and  moral. 

1.  Physical  SYiipxoMS. — The  physical  symp- 
toms consist  in  motor  disorders,  disturbances  of 
the  organic  functions. 

A.  Disorders  of  Motility. — The  principal  dis- 
orders of  this  nature  are :  embarrassment  of  speech, 
tremor,  muscular  weakness,  and  oculo-pupillaiy 
disorders. 

Embarrassment  of  speech  is  the  chief  pathogno- 
monic symptom  of  general  paralysis.  When  it  is 
not  observed,  whatever  may  be  the  other  symptoms, 
we  may  suspect,  but  cannot  affirm  the  existence  of 
general  paralysis.  The  importance  of  its  study  will 
therefore  be  recognized.  This  hesitation  in  speech 
is  very  difficult  to  describe,  but  when  one  is  accus- 
tomed to  hear  it,  it  becomes  easy  to  perceive  all  its 
characters,  even  the  slightest  shades  of  difference,  ex- 
cept in  its  beginning  when  it  is  ouly  perceptible  to 
practised  ears.  At  first  this  hesitancy  is  not  con- 
tinuous, and  only  manifests  itself  in  an  intermittent 
fashion. 

When  the  patient  rises  from  meals  or  when  he  is 
fatigued  by  reading  or  by  a  lengthy  conversation,  a 
syllable  is  badly  pronounced  and  repeated,  there  is 
what  we  call  an  impediment;  the  emission  of  the 
sound  remains  suspended  on  the  impeded  syllable, 

Mext.  M£D.— 27. 


426  I^fSAIHTT  WITH  DISEASES  OF  BHAIN. 

and  then  after  this  faux  pas  which  lasts  only  a 
second,  he  again  becomes  at  ease.  Or  perhaps  the 
speech  becomes  slow,  drawling,  and  as  it  were 
intoned.  Gradually  this  hesitancy  increases  and 
becomes  perceptible  by  every  one.  It  assumes  two 
rather  distinct  types:  the  ataxic,  consisting  in  a 
species  of  incoordination  of  speech  which  is  wander- 
ing, confused,  and  precipitate  and  full  of  mistakes ; 
and  the  paralytic  type,  consisting  in  a  staccato  and 
sing-song  slowness,  a  regular  syllableizing  of  words 
and  j)arts  of  words.  This  last  is  most  frequent 
in  paralytic  dementia  and  in  females. 

In  the  first  type  of  speech  each  emission  of  sound, 
every  beginning  of  a  word  or  sentence  is  preceded  by 
a  series  of  fibrillary  ataxif  orm  startings  of  the  lips,  so 
that  there  almost  always  elapses  a  certain  space  of 
time  between  the  first  effort  and  the  final  enunciation. 
To  be  assured  of  this  the  patient  may  be  asked  to 
pronounce  difiicult  words,  and  as  it  is  usually  the 
labials  that  are  worst  articulated  on  account  of  his 
inability  to  manage  his  lips  from  his  ataxia,  it  is  best 
to  ask  him  to  repeat  words  with  labials  and  without 
syllables  that  might  aid  him,  such  as  immovability ^ 
incompatibility^  or  words  v>nth  Unguals  and  dentals 
such  as  artilleryman  of  artillery. 

Tremor  is  one  of  the  first  phenomena  to  appear 
in  the  beginning  of  general  paralysis ;  the  very  first 
according  to  Charles  Lasagne.  It  affects  most  the 
tongue,  the  lips,  the  muscles  of  the  face  and  of  the 
legs    and    arms.      This    tremor,    esi^ecially    at    the 


g£:n:ekai.  pAfiALY^is  (fiest  pideiod).         42? 

beginDing,  is  not  a  tremor  en  masse,  like  that  of 
alcoholism,  for  example,  it  is  a  very  fine  ataxic,  and 
what  is  called  a  fibrillary  tremor.  It  is  intermittent 
and  shows  itself  particularly  when  the  patient  is 
about  to  make  an  effort.  If  he  wants  to  speak  all 
the  muscles  of  his  lips  and  even  of  his  face  enter  into 
play,  and  fibrillary  twitching,  more  or  less  marked, 
occur  before  and  duriug  the  emission  of  the  word. 
Projection  of  the  tongue  out  of  the  mouth  is  done 
in  a  jerky  manner,  and  its  retention  outside  is  very 
difficult  (trombone  movement,  Magnan).  In  the 
hands  the  tremor  is  yet  more  pronounced  when  the 
patient  makes  an  effort  to  carry  tbem  to  the  mouth, 
to  button  the  clothing,  to  pick  up  any  small  object, 
or  to  perform  any  operation  requiring  precision  and 
adroitness.  The  handwriting  is  changed,  finely 
tremulous,  covered  with  erasures,  full  of  omissions 
and  faults  of  grammar  and  spelling  (dysgrammatic 
and  ataxic  writing).  In  the  lower  limbs  the  tremor 
is  marked  while  walking,  and  is  notably  so  when 
the  patient  is  made  to  turn  around  quickly.  The 
tremor  of  general  paralysis  falls  into  the  same  class 
as  those  of  Basedow's  disease  and  alcoholism,  the 
vibratory  or  rapid  tremor  of  Charcot  (eight  to  ten 
vibrations  per  second).  It  differs  therefore  in  this 
respect  from  that  of  paralysis  agitans,  from  senile 
and  mercurial  tremors,  which  count  onlj  four  to  six 
vibrations  each  second. 

The   muscular   enfeeblement  is  rather    a  paresis 
than  a  paralysis.     The  muscular  power  is  certainly 


42S  IXSA^*ITT  TTITS  DISEASES  OP  BBAlIf. 

diramisLecl,  but  to  a  less  extent  than  would  be 
inferred  from  the  awkwardness  and  disability  of  the 
patients.  Indeed  the  dynamometer  and  the  myo- 
graph indicate  an  average  muscular  strength  prop- 
erly speaking  up  to  a  late  period  of  the  malady.  The 
patients  are  nevertheless  quickly  fatigued  and  are 
incapable  of  any  great  effort.  The  myographic 
traces  obtained  in  them  (Chambard)  are  character- 
istic. The  line  of  ascent  is  more  irregular  and  the 
line  of  piiysiological  tetanus  is  interrupted  by  more 
or  less  extended  ataxic  contractions. 

The  oculo-pupillary  disorders  consist  chiefly, 
either  in  an  exaggerated  contraction  of  the  pupils 
(myosis)  which  may  become  mere  pinholes,  or, 
what  is  more  common,  an  inequality  of  their  dila- 
tation. If  this  last  symptom  only  is  looked  for,  it  is 
certainly,  as  has  been  intimated,  not  a  constant  one, 
and  it  is  wanting  in  about  one-third  of  the  cases; 
but  if  all  oculo-pupillary  symptoms,  exaggerated 
contractions,  inequality  of  pupils,  etc.,  are  noted,  it 
is  very  exceptional  that  none  are  met  with.  An 
excessive  myosis  may,  moreover,  mask  an  inequality 
too  slight  to  be  apparent  under  such  conditions,  as 
in  some  cases  this  inequality  is  revealed  under  the  use 
of  belladonna.  Much  importance  has  been  attributed 
to  the  question  as  to  which  pupil  was  affected,  and 
an  intimate  relation  has  been  sought  for  between 
the  side  of  the  most  dilated  pupil  and  the  mental 
form  of  the  disease.  It  has  been  said  that  the  right 
is  larger  in  the  depressive  foi-ms  and  the  left  in  the 


GENERAL  PAKALTSIS  (fIEST  PEEIOD).  429 

expansive  forms.  It  is  generally  recognized  as  re- 
gards which  pupil  is  altered,  that  it  is  the  one  that  is 
most  dilated,  either  from  some  disorder  of  the 
sympathetic  innervation  or  from  that  of  the  motor 
oculi,  and  this  fact  has  its  importance  since  it  may 
indicate  in  some  measure  in  which  hemisphere  the 
lesions  predominate.  Aside  from  their  contraction 
or  unequal  dilatation,  the  pupils  may  be  deformed, 
ragged,  and  may  not  react  under  the  effect  of  light 
or  accommodation.  Lastly,  various  other  ocular 
troubles  may  exist,  such  as  amaurosis,  ptosis,  achro- 
matopsia, erythropsia  (Ladame),  nystagmus,  etc. 

B.  DisoRDEKS  OF  SENSIBILITY. — Cutaiieous  an- 
aesthesia, particularly  of  certain  regions,  and  notably 
in  the  anterior  thorax,  has  been  observed  as  a  sign  of 
beginning  general  paralysis.  What  seems  more  sure 
is  that  from  the  moment  the  disease  has  fairly  started 
the  tactile  sensibility  is  dulled,  although  it  is  difficult 
to  definitely  establish  this  fact  on  account  of  the 
demented  condition  of  the  patients.  The  same  is 
true  of  special  sensibility  which  becomes  less  perfect. 
Some  writers  indeed  attribute  a  great  importance  to 
the  enfeeblement  of  the  gustatory  and  olfactory  sen- 
sibility. As  regards  the  reflexes,  their  condition  is 
variable.  According  to  Bettencourt-Rodrigues  the 
cutaneous  reflexes  are  generally  diminished  and  the 
tendon  reflexes  exaggerated. 

C.  DlSORDEES    OF    THE    ORGANIC    FUNCTIONS. 

These  disorders  are  but  little  pronounced  in  the  first 


430  rySAXITT  WITH  DISEASES  OP  BRAIN. 

psricd:  digestive  disturbances  are  the  ones  that  pre- 
dominate, and  these  consist  in  exaggeration  of  the 
appetite  and  a  tendency  to  constipation. 

2.  Intellectual  axd  Mokal  Disturbances. — 
The  intellectual  and  moral  disorders  may  be  summed 
up  in  a  general  enfeeblement  of  all  the  faculties. 

The  memory  becomes  more  and  more  untrust- 
worthy, the  patients  lose  their  recollections  of  dates, 
names  of  recent  events,  of  what  they  have  done  the 
day  previous  or  Avish  to  do  at  the  moment,  while  pre- 
serving at  the  same  time  their  former  recollections ; 
their  imagination,  their  reasoning  powers,  their  power 
of  attention  and  of  Avill  become  more  and  more  ob- 
scured. They  may  still  be  able  to  fulfil  their  social 
duties,  and  even  to  carry  on,  by  a  sort  of  acquired 
habitude,  some  easy  mental  work  that  requires  no 
effort  of  the  imagination  or  initiative,  but  they  are 
incapable  of  serious  labor.  They  make  serious  errors 
in  calculation,  they  leave  their  sentences  unfinished, 
their  conversation  is  disconnected,  they  lose  their 
way  in  the  streets. 

Morally  they  become  indifferent  as  to  conduct  and 
show  a  j^rogressive  alteration  of  the  affective  feelings, 
together  Avith  marked  irritable  weakness. 

In  a  word  they  fail  more  and  more  and  realize  in 
an  intellectual  and  moral  point  of  view  the  ordinary 
tableau  of  dementia. 


GENEEAL  PARALYSIS  (SECOND  PEEIOD).  431 

Second  Period.     (Period  of  Full  Development). 

The  transition  from  the  first  to  the  second  period 
is  an  artificial  one,  based  on  no  very  well  defined 
symptoms.  It  is  recognized  by  the  progress  of  the 
above  described  symptoms,  especially  the  dementia 
and  the  paralysis,  and  freqnently  also  by  an  increase 
of  fiesh  that  occurs  at  this  time. 

Apart  from  the  epiphenomena  of  various  kinds 
that  may  supervene,  it  is  essentially  constituted  by 
the  progressive  accentuation  of  the  already  existing 
symptoms.  The  speech  becomes  gradually  more 
and  more  embarrassed,  till  at  the  end  of  this  stage 
it  finally  becomes  almost  unintelligible ;  the  tremor, 
the  paresis,  the  uncertainty  of  the  movements  and 
of  progression  increases;  the  intelligence  fails,  the 
ideas  are  more  and  more  circumscribed  and  are 
gradually  limited  to  the  material  matters  of  life,  the 
simple  needs  of  existence.  The  patients  come  to 
have  no  idea  of  what  goes  on  around  them;  they 
commit  absurd,  automatic  and  childish  acts,  lose 
their  sense  of  propriety,  do  not  clothe  themselves 
properly,  they  gather  up  filth,  pebbles  and  scraps  of 
paper  with  which  the}^  fill  their  pockets.  They  for- 
get that  they  are  married,  that  they  have  children, 
they  live  in  the  monotonous  repetition  of  the  same 
words  and  ideas.  There  is  sometimes  added  to  the 
other  oculo-pupillary  disturbances  diplopia,  amau- 
rosis, etc. ;  and  to  the  muscular  disorders,  contrac- 
tures, particularly  in  the  head  which  becomes  rigid 


432  rySA^OTT  WITH  DISEASES  OF  BEATS'. 

and  does  not  toncli  the  pillow  in  tlie  dorsal  decubitus. 
Very  often  also  there  is  a  kind  of  mumbling,  a 
sort  of  movement  of  rumination  or  tasting,  that 
is  sometimes  continuous,  together  with  a  char- 
acteristic grinding  of  the  teeth  that  may  go  so  far 
as  to  wear  away  their  surface  and  which  is  heard  at 
quite  a  long  distance. 

The  muscular  weakness  gradually  increases  so 
that  walking  is  more  and  more  impeded,  falls  are 
frequent,  the  patients  have  difficulty  in  carr^dng 
their  food  to  their  mouths.  Nevertheless  they  gain 
considerably  in  flesh,  and  they  become  more  and 
more  voracious  and  gluttonous.  Finally,  they  have 
a  peculiar  fades  that  has  been  called  the  paralytic 
masJc^  and  which  consists  in  an  earthy  tint  and  flac- 
cidity  of  the  cheeks,  with  obliteration  of  the  cutane- 
ous folds,  particularly  the  naso-labial  grooves,  that 
deprives  the  face  of  all  vivacity  and  expression. 

After  a  longer  or  shorter  duration  of  this  period, 
which,  according  as  it  is  complicated  or  not  with  con- 
gestive, phenomena,  may  last  months  or  even  years, 
the  patient  gradually  passes  into  the  terminal  stage, 
which  is  marked  by  a  characteristic  symptom ;  the 
relaxation  of  the  sphincters,  the  result  of  which  is 
the  *' untidy"  (guteiix)  condition. 

Terminal  Period. 

At  the  moment  the  patient  begins  to  soil  himself 
he  enters  into  the  final  stage  of  his  disease. 

He  usually  begins  by  Avetting  his  bed  at  night, 


GENEEAL  PAEALTSIS  (TEE:MrN'AL  PEETOD).       433 

then  his  clothing,  first  only  occasionally,  later,  con- 
tinuously; he  gradually  begins  to  allow  his  faeces  to 
escape,  and  at  last  becomes  altogether  filthy;  his 
vesical  and  rectal  sphincters  are  paralysed.  More 
rarely  this  paralysis  reveals  itself  by  a  retention  of 
urine  or  of  fecal  matter. 

From  this  time  on  the  paralytic  becomes  more  and 
more  degraded ;  he  walks  clumsily  or  in  an  ataxic 
fashion,  is  always  on  the  point  of  falling,  and  soon 
is  unable  to  keep  the  erect  posture ;  he  cannot  dress 
himself,  or  perform  the  simplest  acts;  he  ignores 
propriety,  eats  gluttonously  and  filthily  and  even 
eats  his  own  excrements.  The  physiognomy  is 
that  of  hebetude  and  absolute  dementia;  pupillary 
inequality  is  commonly  very  marked ;  the  speech  is 
only  an  incomprehensible  stammering,  sometimes 
complicated  with  true  aphasia ;  the  grinding  of  the 
teeth  and  the  mumbling  when  present  are  very 
noticeable;  the  spasmodic  tremors  of  the  hands,  the 
lips  and  the  tongue  increase;  the  contractures, 
especially  in  the  neck,  are  very  manifest ;  sensibility 
is  almost  or  quite  abolished;  paralysis  of  the  pharynx 
is  added  to  that  of  the  sphincters,  so  that  the  food, 
bolted  down,  is  often  accumulated  in  the  isthmus  of 
the  throat  and  sometimes  causes  in  this  way  asj^hyxia 
which  maybe  fatal.  Finally,  failing  constantly,  the 
patients  become  bedridden  and  shortly  there  appear, 
under  the  influence  of  the  alterations  in  the  nervous 
system,  trophic  disorders  and  various  forms  of  de- 
generation such]  as  cachectic  wasting,  tendency  to 


434  INSANITY  WITH  DISEASES  OP  BKAIN. 

fractures  and  luxations,  althougli  denied  by  Chris- 
tian, eiythemas,  abscesses,  mal  perforant  of  the 
foot,  spontaneous  shedding  and  dystrophy  of  the 
nails  and  teeth,  heematomas  of  the  ear,  purpura, 
sloughs  of  the  sacral  region  and  buttocks,  and  of 
the  heel,  etc.  Such  of  these  complications  as  give 
rise  to  a  free  suppuration,  maj^,  by  the  revulsion 
thus  produced,  cause  a  temporary  improvement  and 
regression  of  the  evolution  of  the  symptoms.  It  has 
been  also  remarked  that  in  spite  of  the  general  bad 
condition  of  the  patient,  all  these  incidental  disorders, 
fractures,  abscesses,  boils,  tnal perforant^  etc.,  haA^e 
a  surprising  tendency  to  recover. 

The  aural  haBmatoma,  the  only  one  of  these  com- 
plications that  from  its  frequency  and  the  discussions 
to  which  it  has  given  rise,  merits  our  attention  here, 
may  be  either  single  or  double.  This  form  of  blood 
tumor  is,  it  is  true,  sometimes  met  with  in  other 
forms  of  mental  disorder,  especially  in  epilepsy, 
idiocy,  melancholia,  mania,  etc.,  as  well  as  also  in 
professional  pugilists,  but  it  is  particularly  frequent 
in  general  paralysis.  The  extravasation  is  often  pro- 
duced with  great  rapidity  and  develops  within  a  few 
hours,  but  in  most  cases  it  takes  several  days  for  its 
full  growth.  The  tumor  may  vary  in  size  from  that 
of  a  hazel  nut  to  that  of  a  pigeon's  ^^^^^ ;  it  occupies 
all  the  pavilion  of  the  ear  but  leaves  the  lobule  intact. 
lu  the  beginning  it  has  a  crepitant  feel  to  the  finger 
and  when  incised  it  discharges  blood  mixed  with 
serous  fluid.     In  spite  of  its  apparent  gravity  the 


GENERAL  PARALYSIS  (TERMINAL  PERIOD).       435 

tumor  heals  almost  always  in  the  course  of  a  few 
weeks,  but  there  remains  a  deformity  that  is  gener- 
ally characteristic  and  indelible.  In  an  anatomical 
point  of  view  hsematoma  is  formed  by  an  extrava- 
sation situated  according  to  some  (Foville)  under 
the  perichondrium,  according  to  others  (Mabille) 
between  the  cartilage  and  the  skin ;  and  according 
to  some  (Vallon)  in  the  body  of  the  cartilage. 

The  pathogeny  is  no  better  understood.  Accord- 
ing to  some  authorities  hgematoma  is  always  the 
result  of  a  traumatism,  and  of  blows  in  particular. 
According  to  others  it  is  spontaneous  and  is  due 
to  a  disorder  of  innervation  of  the  great  sympathetic. 
It  is  probable  that  its  essential  cause  is,  in  fact,  in  a 
disorder  of  the  circulation,  and  that  in  consequence 
of  this  preparatory  state,  the  slightest  shock,  such  as 
the  mere  friction  of  the  ear  on  the  clothes,  may  give 
rise  to  its  appearance. 

During  this  period  the  patient  fails  steadily  in  his 
intelligence  and  moral  qualities ;  his  ideas  are  grad- 
ually contracted  and  abolished;  he  recognizes  no  one, 
feels  no  emotion  or  sentiment,  he  remembers  nothing, 
his  only  manifested  want  is  that  for  food,  and  he 
finishes  by  being  reduced  finally,  as  has  been  said, 
to  a  mere  digestive  tube. 

Arrived  at  this  stage  the  paretic  presents  the  picture 
of  a  most  profound  and  lamentable  degradation,  he 
has  in  him  nothino-  more  of  his  human  nature  and 
falls  actually  into  the  condition  of  a  lower  order  of 
being. 


43 G  rN'SANITT  WITH  DISEASES  OF  B'RAl'S. 

Death  is  the  invariable  termination  of  this  stage. 
It  occurs  either  from  the  advancing  physical  failure 
(paralytic  marasmus  or  cachexia),  or  as  the  result  of 
some  complication  (incidental  diseases,  hypostatic 
pulmonary  congestion,  etc.),  or  finally  from  the  ef- 
fects of  congestive  attacks.  The  frequency  and  im- 
portance of  these  latter  necessitates  a  word  in  regard 
to  them. 

Cerebral  congestion  plays  a  very  important  part  in 
the  course  of  general  paralysis.  It  may  announce  the 
beginning  of  the  disorder  as  well  as  terminate  it  sud- 
denly by  death  in  its  later  stages.  It  may  also  man- 
ifest itself  at  any  stage  of  its  course  or  duration. 
This  cerebral  cono^estion  reveals  itself  under  the  most 
diverse  forms,  so  that  some  authors,  like  Aubancl  and 
Marce  have  noted  some  six  or  eight  varieties.  In 
reality  those  that  occur  under  the  form  of  congestive 
attacks  and  constitute  a  true  complication  are  the 
following:  (1)  comatose;  (2)  hemiplegic ;  (3)  apo- 
plectiforni;  (4)  epileptiform. 

In  the  comatose  form  the  patient  begins  by  show- 
ing a  tendency  to  somnolence,  to  hebetude,  to 
bodily  and  mental  inertia.  His  face  becomes  con- 
gested and  in  a  few  hours  lie  reaches  the  condition  of 
complete  coma  with  muscular  relaxation  and  absolute 
insensibility,  without  usually  any  appreciable  diffi- 
culty of  respiration.  These  attacks  are  ordinarily 
not  serious,  and  pass  off  rather  rapidly  under  proper 
treatment. 

In    the   hemiplegic    form    the    paralysis    occurs 


GENEEAL  rAKALYsis  (tee:mi^^al  pebiod).     437 

sucldenl}^,  so  to  sjDeak,  without  any  premoDitions. 
The  patient  all  at  once  drops  whatever  he  may  have 
in  his  hands  or  one  of  his  limbs  gives  way  and  a 
hemiplegia  or  monoplegia  quickly  appears,  which 
lasts  for  a  variable  time  but  as  a  rule  tends  to  dis- 
appear or -become  diminished  within  a  few  days. 

In  the  following  described  form  we  see  a  genuine 
attack  of  the  apoplectiform  type.  The  patient  falls 
as  if  struck  by  lightning  and  loses  consciousness ;  a 
comatose  condition  follows  with  deeply  congested 
visage,  loud  stertorous  respiration,  foam  at  the  lips, 
muscular  resolution,  and  relaxation  of  the  sphincters. 
Death  may  occur  at  once,  but  generally  this  con- 
dition passes  off  in  a  few  minutes,  and  after  a  longer 
or  shorter  period  of  transition,  characterized  by  hebe- 
tude and  somnolence,  the  patient  comes  to  himself, 
with  still  in  some  cases  a  transitory  hemiplegia  or  a 
weakness  of  the  vesical  and  rectal  sphincters. 

The  epileptiform  attack,  the  most  frequent  and 
most  serious  of  all  the  congestive  complications  of 
general  paralysis,  also  manifests  itself  by  a  sudden 
loss  of  consciousness  with  initial  cry,  pallor,  fol- 
lowed by  redness  of  the  face,  bloody  foam  at  the 
mouth,  and  finally  convulsions,  sometimes  general, 
sometimes  and  more  often,  limited  to  one  side  or  to 
one-half  of  the  face,  to  one  arm  or  limb,  and,  as  a 
rule  accompanied  by  a  rise  of  temperature  which 
may  reach  to  104=^  F. 

In  the  great  majority  of  the  cases  the  epilepti- 
form attack  is  not  an  isolated  one,  others  occur  dur- 


438  IXSAISriTY  WITH  DISEASES  OF  BBAlN. 

ing  the  same  day  separated  b}^  a  longer  or  shorter 
interval  of  coma ;  sometimes  there  is  a  regular  status 
epilepticus.  These  attacks,  which  may  reappear 
many  times  in  the  course  of  the  disease,  especially 
in  its  later  stages,  are  always  followed  by  an  aggra- 
vation of  its  symptoms,  and  occasionally  by  death, 
which  may  be  predicted  by  the  progressive  elevation 
of  the  temperature.  They  often  leave  behind  them 
various  complications  such  as  hemiplegia,  contrac- 
tures, aphasia,  etc. ,  generally  transitory  and  capable 
of  a  certain  degree  of  amelioration. 

The  epileptifonn  attacks  of  general  paralysis, 
although  not  differing  essentially  in  a  clinical  point 
of  view  from  true  epilepsj^,  are  yet  separated  from 
its  idiopathic  form  in  many  respects,  and  enter  into 
the  category  of  symptomatic  epilepsies. 

IxsAKiTY  Connected  witu  Paralytic  Dementlv. 
{Paralytic  Lisanity). 

Paralytic  dementia  of  which  the  description  has 
been  sketched  in  the  foregoing  pages,  is  the  most 
simple  aud  uncomplicated  type  of  general  paralysis, 
its  fundamental  expression.  It  presents  itself  in 
this  form  more  frequently  than  is  generally  sup- 
posed, if  we  take  account  not  only  of  the  cases  ob- 
served in  the  asylums  but  also  of  all  those  that  exist 
outside  institutions  of  this  kind,  especially  in  females, 
and  which  are  more  or  less  unrecoo-nized.  But  be 
this  as  it  may,  in  a  large  number  of  cases  there  are 
superadded  to  the  symptoms  described  varied  con- 


GENERAL  PARALYSIS  (PARALTTIC  INSAKITY)  .    439 

ditions  of  insanity,  that  is  to  say,  a  generalized 
insanity  of  the  maniacal  or  melancholic  type  is  as- 
sociated with  the  paralytic  dementia,  and  impresses 
upon  the  latter  cerebral  conditions  certain  special 
characters  that  deserve  our  attention. 

The  form  of  insanity  that  occurs  most  frequently 
in  paralytic  dementia,  at  least  in  its  beginning,  is 
maniacal  excitation  with  ambitious  delusions.  This 
maniacal  condition,  which  usually  opens  the  scene, 
consists  in  a  more  or  less  marked  exaltation  of  the 
intelligence,  the  feelings,  and  the  bodily  functions 
(functional  dynamy),  in  a  marked  mental  and  physi- 
cal hyperactivity,  an  exaggerated  desire  for  move- 
ment, ideas  of  ambition,  of  invention,  of  riches,  with 
tendencies  to  absurd  thefts,  to  erotism,  to  alcoholic 
excesses,  etc.,  etc.  Later  as  the  dementia  increases 
this  exaltation  of  the  faculties  gradually  disappears, 
and  gives  place  to  delusions  of  greatness  that  are 
absolutely'' typical,  the  characteristic  of  which  is  their 
absurd,  mobile,  contradictory  and  incoherent  char- 
acter. These  characters  are  due  to  the  dementia 
which  forms  the  basis  of  the  mental  condition. 
The  delusions  of  the  patients  include  all  possible 
grandeurs.  They  have  immense  wealth,  millions 
and  milliards,  they  are  princes,  dukes,  bishops, 
popes;  they  boast  to  the  fullest  degree  strength, 
health,  fortune,  business,  success,  their  family,  the 
number  of  their  children,  etc.  Everything  in  their 
claims  is  superlative.  Satisfaction  and  happiness 
are  shown  in  all  their  being.     In  general,  and  apart 


440         iN-SA^^iTT  wirn  diseases  of  BRArs'. 

from    their   temporary  spells  of    passion,  they   are 
good-natured,  philanthropic  and  generous  to  excess. 

Next  to  maniacal  excitation,  acute  melancholia  is 
the  most  frequent  form  of  insanity  obsei*ved  in  the 
beginning  or  during  the  course  of  paralytic  demen- 
tia. As  we  know,  it  Avas  long  held,  with  Bayle, 
that  ambitious  delusions  were  constant  and  pathog- 
nomonic in  general  paralysis,  and  it  required  all  the 
efforts  of  Baillarger  to  establish  the  fact  that  in  this 
disease  the  insanity  was  rather  frequenth'  of  the 
melancholic  tj^pe.  As  this  author  has  shown  the 
delusions  in  these  cases  generally  manifest  them- 
selves in  absurd,  incoherent  hypochondriacal  ideas 
relating  to  the  organic  functions  and  especially 
those  of  the  digestive  tract.  The  patients  claim 
that  their  aliments  do  not  pass,  that  they  have  no 
mouth,  no  arms,  they  are  constipated,  obstructed, 
rotten,  they  are  dead,  etc.  More  rarely  they  suffer 
from  ideas  of  persecution,  of  culpability,  of  ruin, 
dishonor,  etc. ,  and  in  these  cases  we  may  meet  with 
hallucinations  of  hearing,  sight  or  touch, — moreover 
usually  denied — which  seem  to  be  less  common  in 
in  the  other  forms  of  paralytic  insanity.  Whatever 
may  be  the  form  of  the  delusion  it  is  essentially  ab- 
surd, silly,  and  incoherent.  There  are  also  very 
frequently  added  refusal  of  food  and  ideas  of 
suicide. 

After  these  two  varieties  of  insanity,  those  most 
frequently  met  with  in  paralytic  dementia  are :  acute 
mania,  with  very   active  excitement,    delusions   of 


GENERAL  PABALYSIS  (PAEALTTIC  rNTSANITT).    441 

greatness,  incoherence,  and  violence;  hyperacute 
mania  or  acute  delirium,  which  then  takes  the  name 
of  acute  paralytic  delirium,  and  constitutes  the  most 
acute  and  rapidly  fatal  of  general  paralysis;  finally, 
simple  melancholic  depression  and  sometimes  mel- 
ancholia with  stupor. 

The  characteristic  of  all  these  conditions,  of  what- 
ever form,  is  the  absurdity  of  the  conceptions  due  to 
the  dementia. 

These  forms  of  insanity  are  associated  with  para- 
lytic dementia  in  many  different  ways. 

In  certain  cases  an  attack  of  maniacal  excitement 
with  functional  exaltation  of  potency,  breaks  out  at 
the  very  beginning  of  the  disorder,  and  continues, 
in  more  or  less  acute  attacks  throughout  its  whole 
course.  (General  paralysis  of  the  expansive  type,  the 
maniacal  type,  the  ambitious  type).  In  other  cases 
melancholia  with  hypochondriacal  delusions  accom- 
panies the  affection  from  beginning  to  end.  (Gen- 
eral paralysis  of  the  melancholic,  depressive  and 
hypochondriacal  types). 

Occasionally  also  the  insanity,  after  having  ap- 
peared in  the  melancholic  or,  what  is  more  frequent, 
the  maniacal  form,  may  disappear  either  at  the  com- 
mencement or  during  the  course  of  the  disorder, 
leaving  behind  it  only  the  symptoms  of  paralytic 
dementia.  In  such  a  case  there  is  produced  what  is 
called  a  remission,  a  clinical  feature  that  has  been 
variously  interpreted,  but  which  ought  to  be  consid- 
ered with  Baillarger,  as  the  disappearance  of   the 

Mbnt.  Med.— 28. 


442  EN-SAOTTT  WITH  DISEASES  OF  BRAIN. 

attack  of  insanity  with  persistence  of  the  paralytic 
dementia,  which  continues  its  progress  whether 
complicated  or  not  by  new  attacks  of  maniacal  or 
melancholic  paralytic  insanity. 

In  other  cases  still,  the  ambitious  mania  disappears, 
but  only  to  give  place  to  an  attack  of  melancholia, 
generally  hypochondriacal  in  its  character,  an  altern- 
ation which  may  be  many  times  reproduced  with  or 
without  intermediate  remissions,  but  generally  in  a 
less  regular  manner  than  is  the  case  in  true  double 
form  insanity.  This  is  what  has  been  designated 
general  paralysis  of  double  form  or  circular  paresis. 
According  to  Baillarger's  theory  these  cases  are  not 
to  be  explained  by  a  modification  of  the  paralytic 
dementia  which  itself  remains  fixed  and  unchangeable, 
but  by  the  circular  character  taken  on  by  the  in- 
sanity instead  of  its  continuing  always  the  same. 
Paralytic  double  form  insanity  and  the  remissions 
are  observed  especially  among  the  subjects  of  heredity 
and  more  particularly  amongst  those  with  heredity 
of  vesania. 

In  some  cases  finally,  the  attacks  of  paralytic  in- 
sanity, whether  mania,  melancholia  or  circular,  occur 
and  continue  for  a  longer  or  shorter  period,  without 
the  symptoms  of  paralytic  dementia  manifesting 
themselves.  Recovery  or  death  may  take  place 
without  their  appearance  (latent  general  paralysis). 

Only  by  thus  considering  the  relations  of  general 
paralysis  and  insanity  by  their  possible  disassociation, 
are  we  able  to  comprehend  the  very  diverse  ways  of 


GENEEAL  PAEALTSIS  (PARALTTIC  I:N-SANITY)  .    443 

manifestation  of  the  latter,  which  would  be  inex- 
plicable were  w^e  forced  to  admit,  according  to  the 
unitary  theory,  that  insanity  formed  one  of  the  es- 
sential constituent  elements  of  general  paralysis. 

CouESE.  DuEATiON.  Teemination. — General  pa- 
ralysis may  be  either  primary  or  consecutive  to  some 
other  disease,  generally  one  of  the  nervous  centres, 
like  locomotor  ataxia,  for  example.  When  it  com- 
mences thus  with  spinal  symptoms,  it  is  called  as- 
cending general  paralysis,  or  general  paralysis  by 
propagation. 

Here  it  should  be  stated  that  general  paralysis  and 
tabes  are  diseases  absolutely  similar  in  origin  and 
nature  and  that  they  have  very  close  relations  with 
each  other.  It  is  not  uncommon  to  see  general  paral- 
ysis beginning  or  terminating  with  the  symptoms  of 
ataxia,  and  even  in  some  cases  presenting  through- 
out its  whole  course  a  mingling  of  spinal  and 
cerebral  symptoms. 

The  usual  course  of  paralytic  dementia,  when  un- 
complicated, is  progressive  and  the  duration  of  all 
three  periods  averages  two  or  three  years  in  the  male 
and  three  or  four  in  the  female,  the  longer  duration 
in  the  latter  being  due  to  the  less  frequency  of  con- 
gestive complications.  Its  invariable  termination  is 
in  death. 

When  paralytic  dementia  is  accompanied  with  in- 
sanity, however,  its  course  may  be  modified.  When 
the  insanity  is  of  the  continuous  type  and  persists  all 


444  IXSAlSriTT  WITH  DISEASES  OF  BRAIN. 

the  time,  no  change  occurs  in  the  progress  of  the  dis- 
order except  in  cases  when  it  takes  on  the  hyperacute 
form  (paralytic  acute  delirium)  when  death  super- 
venes in  from  ten  to  fifteen  days.  If,  however,  the 
insanity  is  of  the  remittent  type  (remissions)  or  the 
circular  type  (alternating  general  paralysis)  the 
duration  will  be  longer  and  may  extend  over  seven, 
eight,  or  even  ten  years  or  more. 

Finally,  when  paralytic  insanity  appears  alone 
(latent  general  paralysis),  recovery  may  occur  either 
temporary  or  definite,  the  incurable  lesions  of  para- 
lytic dementia  not  having  yet  developed. 

Pathological  Anatomy. — The  lesions  commonly 
encountered  in  general  paralysis  are  of  two  kinds, 
macroscopic  and  microscopic. 

Macroscopic  Lesions. — The  dura  mater  is  very 
often  thickened,  adherent  to  the  cranial  walls,  with 
here  and  there  osseous  deposits  and  in  certain  cases 
with  false  membranes. 

The  arachnoid  is  also  thickened  and  opaque,  dis- 
tended by  the  engorged  vessels,  and  it  has  patches 
of  granulations  of  conjunctive  tissue  particularly 
along  the  great  longitudinal  fissure. 

The  pia  is  usually  injected  and  covered  with  ar- 
borizations. It  sometimes  presents  whitish  streaks  in 
the  periphery  of  the  vessels. 

The  meninges  are  almost  always  adherent  to  the 
cortex  of  the  brain.  These  adhesions,  noticed  by  the 
earliest  observers,  are  properly  considered  to  be  the 


GENERAX  PARALYSIS  (PARALYTIC  INSANITY).     445 

most  characteristic  and  constant  of  the  macroscopic 
lesions.  In  some  exceptional  cases  they  may  be  want- 
ing. Sometimes  they  are  hardly  apparent,  especially 
when  the  patient  succumbs  in  the  early  stages  of 
the  disorder,  the  meninges  then  being  just  barely 
attached  to  the  cerebral  cortex.  Commonly  the 
meninges  in  being  detached  take  with  them  small 
portions  of  the  cortical  tissue,  so  that  after  their 
removal  the  brain  surface  shows  here  and  there 
more  or  less  marked  erosions  or  ulcerations.  The 
most  frequent  seat  of  these  adhesions  is  the  super- 
ficies of  the  cortical  folds  of  the  antero-lateral 
lobes,  particularly  the  horizon  of  the  convolutions 
bordering  the  fissure  of  Rolando.  Sometimes,  on  the 
other  hand,  they  predominate  in  the  occipital  region, 
occasionally  they  are  scattered  over  the  whole  brain. 

The  cortical  layer  is  thinned,  there  is  absorption 
and  atrophy.  It  is  softened  and  comes  away  in  pulp. 
It  separates  the  more  easily  from  the  white  substance 
which  is,  on  the  other  hand,  indurated.  By  scratch- 
ing with  the  back  of  a  scalpel  the  cortical  layer  be- 
comes detached  and  there  is  produced  the  phenom- 
enon of  crests  (Baillarger) ,  that  is,  we  cause  white, 
firm  ridges  or  crests,  entirely  deprived  of  gray 
matter. 

The  lateral  ventricles,  and  especially  the  fourth 
ventricle,  are  lined  with  serous  exudate  and  nearly 
always  show  the  so  called  ependymal  granulations 
(Joire,  Magnan,  and  Mierzejewski).  These  granu- 
lations are  like  bits   of  parchment  or  of  chicken's 


446  rN"SAXITY  WITH  DISEASES  OF  BRAIN. 

flesh;  if  not  at  once  seen  they  may  be  rendered  visi- 
ble by  viewing  obliquely  the  ependymal  surface. 
Sometimes  the  ventricular  parietes  are  full  of  fine 
holes.  The  cavity  of  the  lateral  ventricles  seems 
enlarged. 

In  the  later  stage  the  brain  loses  a  noticeable  part 
of  its  weight,  and  the  inequality  between  the  two 
hemispheres  is  increased.  The  gray  matter  varies 
according  to  the  degree  of  disorganization ;  it  some- 
times assumes  a  slaty  color,  which  is  due,  according 
to  Baillarger,  to  purulent  infection  produced  by  the 
eschars. 

Microscopic  Lesions. — These  lesions  are  observed 
at  once  in  the  vessels,  in  the  interstitial  tissue  or  neu- 
roglia, and  in  the  nerve  substance  proper. 

The  alterations  of  the  vessels,  the  earliest  and 
most  constant  lesions,  consist  first  in  a  considerable 
increase  of  the  nuclei  in  the  walls  of  the  capillaries 
which  gradually  becomed  thickened  and  narrowed. 
Then  extravasations  of  blood  occur,  composed  mainly 
of  white,  globules,  and  the  adventitia,  charged  with 
nuclei  of  new  formation  and  deposits  of  pigment, 
sometimes  presents  miliary  aneurysms. 

At  a  more  advanced  stage  we  observe  in  the  ves- 
sels various  states  of  degeneration,  such  as  colloid  and 
fatty  degenerations. 

The  alteration  of  the  interstitial  tissue,  which 
begins  in  the  inferior  layers  of  the  gray  substance 
and  propagates  itself  from  below  upward,  consists 
in  a  morbid  development  of   the  connective  tissue 


GEKERAL  PAEALTSIS  (PAEALTTIC  INSANITt).  447 

cells,  known  under  the  name  of  spider  cells.  At  the 
same  time  the  neuroglia  increases,  and  according  as 
it  develops,  it  crowds  and  chokes  out  the  cerebral 
cells. 

The  nerve  siTbstance  proper  may  be  relatively 
spared,  and  its  alterations  are  mainly  secondary. 
Its  cells,  compressed  as  we  have  seen  by  the  pro- 
gressive expansion  of  the  connective  tissue,  undergo 
a  series  of  degenerative  lesions ;  they  become  soft- 
ened, lose  their  nuclei,  and  finish  by  a  granular 
fatty  degeneration,  at  the  same  time  as  the  intra- 
cortical  nervous  fibres  disappear  (Tuczek,  Targowla). 
The  white  tissue  resists  longer,  but  finally  succumbs 
in  its  turn :  we  observe  hypertrophy  of  the  cylinder 
axes,  fragmentation  of  the  myeline  sheaths,  and 
their  granular  fatty  degeneration. 

The  cerebellum,  much  more  rarely  affected,  may 
nevertheless  show  softening,  serous  induration, 
atrophy  of  Purkinje's  cells,  etc. 

The  lesions  of  the  brain  extend  as  a  rule  to  the 
cord,  which  is  in  some  cases  profoundly  altered,  and 
its  posterior  and  lateral  columns  sometimes  undergo 
a  sclerotic  degeneration. 

We  also  encounter  lesions  in  the  region  of  the 
great  sympathetic.  According  to  Bonnet  and  Poin- 
carre,  these  lesions,  which  are  very  important,  are 
located  in  the  cells  of  the  ganglia,  which  first  suffer 
a  pigmentary  alteration  and  then  in  time  disappear, 
being  replaced  in  part  by  cellulo-adipose  tissue.  Ac- 
cording to  the  more  recent  researches  of  Popoff,  the 


448  INSANITY  WITH  DISEASES  OF  BRAlN. 

grand  sympathetic  exhibits  in  general  paralysis  two 
kinds  of  lesions:  (1)  thickening  of  the  vascular  walls, 
proliferation  of  interstitial  conjunctive  tissue  of  the 
ganglia ;  (2)  diminution  by  half  and  extreme  pigment- 
ation of  the  cells,  which  undergo  Vacuolization  but 
never  fatty  degeneration. 

The  nerves  are  sometimes  the  seat  of  various  alter- 
ations. Sclerosis  of  certain  cranial  nerves,  atrophy 
of  the  sciatic,  and  also  peripheral  neuritis  have  been 
found. 

Up  to  the  present  the  nervous  lesions  have  mainly 
been  studied  in  the  pathological  anatomy  of  general 
paralysis.  It  is  certain  nevertheless  that  the  viscera 
are  also  altered  and  this  also  merits  attention.  It  is 
not  uncommon,  in  autopsies,  to  find  in  one  or  many 
of  these  organs,  manifest  traces  of  sclerosis  or  of 
softening. 

Diagnosis. — The  diagnosis  of  general  paralysis, 
often  easy  on  account  of  the  assemblage  of  typical 
symptoms  accompaning  the  disease,  may,  neverthe- 
less, in  certain  cases,  present  some  real  difficulties. 
It  will  be  most  convenient  here  to  consider  separately 
the  diagnosis  of  paralytic  dementia  and  of  paralytic 
insanity. 

(1) .  Simple  paralytic  dementia  may  be  confounded 
with  apoplectic  dementia.  It  can  be  distinguished 
from  the  latter  mainly  by  the  fact  that  apoplectic 
dementia,  usually  supervenes  at  a  more  advanced  age 
and  ordinarily  in  atheromatous  subjects;  moreover, 


GENERAL  PARALYSIS  (PARALYTIC  INSANITY) .    449 

it  is  usually  accompanied  with  hemiplegic  symptoms 
which  are  lacking  in  general  paralysis ;  the  embarrass- 
ment of  speech  is  not  the  same ;  pupillary  inequality 
is  often  wanting ;  lastly,  the  sensibility  is  much  more 
marked  and  is  sometimes  characteristic. 

Intracranial  tumors  (cancers,  tubercles,  syphilis, 
cysticerci,  echinococci,  etc.),  may  give  rise  to  enceph- 
alopathies that  are  more  or  less  analogous  to  general 
paralysis.  It  is  rare,  however,  for  their  symptoms  to 
be  as  diffuse  and  as  generalized:  on  the  contrary, 
certain  special  symptoms,  such  as  headache,  amaur- 
osis, vomiting,  partial  paralyses  and  epilepsies,  are 
very  frequent. 

A  diagnosis  is  sometimes  difficult  between  gen- 
eral paralysis  and  multiple  sclerosis  in  its  imperfect 
or  its  cerebro-spinal  form.  In  some  of  these  cases 
there  is  a  genuine  embarrassment.  As  a  rule  the 
signs  of  dementia  are  less  marked  in  multiple  scle- 
rosis; moreover,  certain  physical  signs  such  as 
embarrassment  of  speech  and  tremor  have  different 
characters  from  those  in  paresis. 

The  most  important  and  the  most  delicate  diag- 
nosis, however,  is  beyond  dispute  that  between  the 
true  and  the  pseudo-general  paralysis.  Under  this 
latter  name  it  is  understood  we  include  those  cere- 
bral conditions  clinically  analogous  to  general  paral- 
ysis, but  differing  from  it  in  their  tendency  to 
recovery.  Some  authorities  who  do  not  recognize  in 
principle  the  existence  of  pseudo-general  paralysis 
consider  these  conditions  as  special  forms  of  paresis. 


450  IXSANITT  WITH  DISEASES  OF  BEAlK. 

The  greater  number,  however,  see  in  them  only- 
more  or  less  exact  morbid,  imitations  of  general  paral- 
ysis. Substantially  there  is  between  these  two  ways 
of  viewing  the  subject  only  a  simiDle  difference  of 
the  names  of  special  general  paralysis  and  pseudo- 
general  paralysis,  all  the  world  being  in  accord  as 
to  the  reality  of  the  clinical  facts.  It  is  better 
therefore  to  continue  to  accept  pseudo-general 
paralysis,  just  as  we  admit,  at  present,  pseudo-tabes 
and  2Dseudo-multi23le  scleroses. 

The  pseudo-general  paralyses  are,  for  the  most 
part,  the  result  either  of  an  infection  (syphilitic 
pseudo-general  paralysis) ,  or  of  an  intoxication  (al  ■ 
coholic,  saturnine,  etc.),  possibly  also  of  a  neurosis 
(hysterical,  neurasthenic,  epileptic  pseudo-general 
paral3^sis).  As  the  lamented  Baillarger  insisted,  up 
to  the  last  days  of  his  life,  it  is  not  paralytic  msan- 
ity  that  they  simulate  (there  is  not  and  cannot  be 
anj'  pseudo-paralytic  insanity,  since  paralytic  insan- 
ity is  itself  susceptible  of  cure) ,  but  the  true  general 
paralysis,  properly  so  styled,  or  paralytic  dementia, 
with  or  without  delusions.  They  present  them- 
selves therefore  with  the  symptoms  of  dementia  and 
jDaresis  that  characterize  this  disorder.  The  clinical 
picture  may  be  more  or  less  identical ;  it  is  often  such 
that  any  symptomatic  diagnosis  is  impracticable 
from  the  beginning.  Thus  it  is  certainly  not  from 
the  difference  of  the  symptoms  that  the  distinction  is 
made,  as  has  been  vainly  attempted  by  the  majority 
of  authors.     In  my  opinion  this  distinction  is  only 


GENERAL  PAEALYSIS  (p ARAL YTIC  INSANITY) .    451 

to  be  found  in  the  difference  of  the  course  and  prog- 
nosis and  consequently  in  the  lesions.  As  I  have 
said  already  in  reference  to  syphilitic  pseudo-gen- 
eral paralysis,  the  genuine  general  paralysis  has  a 
progressive  course,  a  fatal  prognosis,  and  irremedi- 
able lesions.  Pseudo-general  paralysis,  whether  in- 
fectious as  in  syphilis,  or  toxic  as  in  alcoholism,  has 
a  regressive  course,  a  relatively  favorable  prognosis, 
and  curable  lesions.  It  follows  therefore  that  the 
diagnosis  between  the  two  depends  essentially  on 
the  radically  different  evolution  in  the  two  cases. 

(2).  Paralytic  insanity  may  be  confounded  with 
simple  insanity  in  the  various  forms  under  which  it 
presents  itself. 

Thus  the  attacks  of  maniacal  excitement  of  the 
beginning  of  general  paralysis  may  be  taken  either 
for  an  attack  of  simple  maniacal  excitement  or  for 
the  excited  period  of  a  double  form  insanity,  which, 
as  we  have  seen,  often  assumes  this  type  of  mania. 
The  diagnosis  is,  in  general,  very  difficult  and  is 
sometimes  even  impossible,  since  at  this  stage  there 
is  not  yet  any  dementia  in  general  paralysis ;  and,  on 
the  other  hand,  the  physical  signs  are  but  little  ap- 
parent, and  also  may  exist  to  the  same  extent  in  double 
form  insanity.  The  two  most  important  diagnostic 
signs  are :  (1)  the  initial  signs  of  mental  weakening 
which  show  themselves  from  the  beginning  in  pare- 
tics ;  (2)  the  good  nature  and  habitual  generosity  of 
these  patients  which,  at  this  period  in  particular,  are 
in  strong  contrast  with  the  usual  maliciousness  of 


452  INSANITY  WITH  DISEASES  OP  BRAIN. 

the  insane  of  the  double  form  type.  The  history  of 
the  case  comes  in  to  remove  all  doubts  by  showing 
in  the  latter  either  prior  attacks  or  a  vesanic  hered- 
ity, often  similar  in  kind. 

When  general  paralysis  has  progressed  and  the 
ambitious  delusions  are  in  full  swing,  it  is  hardly 
possible  to  mistake  it  with  the  insanity  of  exaltation 
(partial  insanity) .  Aside  from  the  fact  that  the  am- 
bitious delusions  of  paralytics  have  a  stamp  of  de- 
mentia, of  absurdity  and  incoherence,  altogether 
lacking  in  the  other,  we  know  also  that  the  exalted  de- 
lirium of  partial  insanity  is  never  a  primary  form,  but 
that  it  succeeds  another  type  of  delusions,  generally 
those  of  persecution;  it  is,  moreover,  accompanied 
by  numerous  hallucinations,  while  hallucinations  are 
rather  rare  in  general  paralysis,  at  least  in  its  mani- 
acal form.  Finally,  taking  into  account  only  the 
insanity  itself,  the  delire  des  grandeurs  of  general 
paralysis  is  a  generalized  insanity,  that  is  to  say,  at- 
tended with  excitement,  while  ambitious  delusions 
form  a  partial  insanity. 

The  acute  mania  of  paralytic  insanity  may  be  taken 
in  its  beginning  for  an  attack  of  acute  simple  mania, 
and  in  the  same  way  the  acute  paralytic  delirium  may 
be  mistaken  for  simple  acute  delirium.  The  diagnosis 
in  these  cases  is  often  very  difficult,  and  in  some 
cases  can  only  be  made  at  the  autopsy.  It  is  necessary 
to  take  into  account  the  age  of  the  patient  and  his 
antecedents  and  to  particularly  look  for  the  physical 
signs  of  general  paralysis. 


GENERAL  PARALYSIS  (PAEALYTIC  INSANITY).     453 

Melancholia  of  paralytic  insanity  may  be  confused 
with  simple  insanity  or  with  the  melancholic  stage 
of  double  form  insanity.  It  must  be  kept  in  mind 
that  as  a  rule  physical  symptoms  and  mental  weak- 
ness are  present  in  general  paralysis.  The  delusions, 
moreover,  take  ordinarily  an  absurd  and  often  typic- 
ally hypochondriacal  form,  although,  as  I  have 
shown,  this  may  also  be  met  with  in  certain  cases  of 
simple  melancholia. 

Paralytic  insanity  may  present  itself  under  the 
form  of  stupor  and  the  patient  neither  speaking  nor 
m.oving,  the  diagnosis  is  almost  impossible.  The  in- 
equality of  the  pupils  is  almost  the  only  differential 
sign  of  any  value. 

It  would  seem  that  when  paralytic  insanity  assumed 
the  alternating  form  that  it  ought  to  be  hard  to  dis- 
tinguish from  double  form  insanity.  This  is  not  the 
fact,  however,  since  in  these  cases  the  physical  symp- 
toms are  usually  more  or  less  marked ;  moreover  the 
return  of  the  attacks  never  occurs  with  the  same 
regularity  as  in  those  of  double  form  insanity. 

Etiology. — The  etiology  of  general  paralysis  has 
always  been  one  of  the  points  most  discussed  in  the 
history  of  this  affection.  The  predominant  opinion 
at  the  present  time  is  that  which  attributes  it  to  the 
joint  action  of  two  causes :  a  predisposing  cause,  rep- 
resented by  a  congestive  or  cerebral  tendency,  usually 
hereditary;  and  an  occasional  cause,  which  is  nearly 
always  syphilis.     At  least  this  is  my  own  opinion, 


454  IN-SANITT  WITH  DISEASES  OF  BEATN". 

as  well  as  that  of  a  great  number  of  authorities, 
especially  in  other  countries. 

We  must  pass  in  review  here  the  principal  pre- 
disposing and  determining  causes,  both  general  and 
individual,  that  influence,  more  or  less,  the  develop- 
ment of  general  paralysis. 

Pkedisposlstg  Causes. — Epochs  and  Countries. — 
The  question  whether  or  not  general  paralysis  existed 
in  tlie  past  centuries  has  been  much  discussed,  and 
if  it  had  been  ever  so  infrequent  it  ought  not  to 
have  completely  escaped  the  attention  of  our  prede- 
cessors. On  the  other  hand  there  is  no  doubt  that 
its  frequency  tends  to  increase  from  day  to  day. 
We  may,  therefore,  conclude  with  certainty  that 
general  paralysis  is  a  contemporaneous  malady  and 
especially  a  disease  of  the  nineteenth  century.  This 
fact  should  be  compared  with  the  marked  predilec- 
tion it  shows  for  certain  countries  and  especially  for 
the  great  centres.  In  a  general  way,  in  fact,  and 
aside  from  certain  exceptions,  it  is  rare  in  uncivil- 
ized lands,  while  on  the  contrary  it  is  very  frequent 
amongst  the  peoples  who  have  reached  their  apogee 
and  are  on  their  decline. 

Western  Europe  and  North  America  are  therefore 
the  i^rincipal  foci  of  this  disease.  In  this  regard  an 
American  author  has  said  that  the  frequency  of  gen- 
eral i)aralysis  in  the  various  countries  may  serve  in  a 
certain  measure  as  the  thermometer  of  the  degree  of 
their  civilization.    It  may  be  admitted,  consequently, 


GENERAL  PAKALTSIS  (PAEALYTIC  rNSANITT).    455 

that  the  excesses  of  civilization  and  the  evil  effects 
of  all  kinds  that  follow,  by  causing  a  cerebral  wear 
and  tear  that  goes  on  augmenting  from  generation 
to  generation,  gradually  diminish  the  power  of 
resistance  of  the  nervous  system  in  the  descendants 
and  create  in  them  a  predisposition  to  degenerative 
cerebral  affections,  and  notably  to  general  paralysis. 
Age. — General  paralysis  is,  as  I  have  elsewhere 
called  it,  a  climacteric  disease,  that  is,  one  associated 
with  a  certain  period  of  existence.  This  period  is, 
as  we  are  aware,  the  apogee  of  life.  M.  Luys  has 
explained  perfectly  the  reason  of  this  by  showing 
that  the  interstitial  framework  of  the  brain,  the 
evolution  of  which  is  continuous,  finds  itself  at  this 
moment  in  a  stataof  critical  proliferation,  in  "a  sort 
of  preparatory  physiological  condition  that  may  inci- 
dentally become  a  pathological  process  under  the  in- 
fluence of  an  incidental  nutritive  hyperexcitation." 
As  regards  the  epoch  of  maximum  frequency  of  gen- 
eral paralysis,  it  is  rather  hard  to  fix  it  absolutely. 
While  it  was  set  at  forty-five,  forty-eight,  and  even 
fifty  years  in  Bayle  and  Calmeil's  times,  it  has  cer- 
tainly decreased  since  then  and,  for  myself,  I  found 
it  at  thirty-eight  in  three  hundred  and  seventy  gen- 
eral paralytics  that  came  under  my  observation  at 
the  Asylum  of  Sainte-Anne.  This  lowering  of  the 
average  age  of  the  malady  speaks  ill,  according  to 
the  English  author  Mickle,  for  the  vitality  of  the 
populations  of  Western  Europe,  at  least,  inasmuch 
as  general  paratysis  is  to  be  considered  as  the  result 


456  INSANITY  WITH  DISEASES  OF  BRAIN. 

of  an  exaggerated  expense  of  vital  force  and  of  a  pre- 
mature senility.  Besides  this  reduction  of  the  age 
at  which  general  paralysis  most  generally  manifests 
itself,  it  is  certain  that  we  tend  to  observe  cases  oc- 
curring prior  to  the  culminating  point  of  life.  In  a 
recent  study  of  these  cases,  which  I  have  called  pre- 
mature general  paralysis,  I  showed  that  it  is  possible 
to  find  cases  under  twenty  years  of  age.  Since  then 
new  facts  have  been  published,  and  it  is  generally 
admitted  now  that  there  is  a  premature  or  precocious 
general  paralysis,  which  commonly  appears  in  the 
form  of  simple  paralytic  dementia,  and  which  seems 
to  be  the  result  of  a  precocious  syphilis,  personal  or 
hereditary.  On  the  other  hand  there  may  occur 
cases  of  late  general  paralysis,  occurring  after  the 
age  of  sixty  or  sixty-five  years.  This  form  of  gen- 
eral paralysis,  called  senile^  also  bears  the  name 
atheroraatous^  since  it  is  nearly  always  accompanied 
with  lesions  of  the  heart  or  arteries. 

Heredity. — ^As  we  have  said  above,  the  most 
important  predisposing  cause  of  general  paralysis  is 
the  congestive  or  cerebral  tendency,  usually  the 
result  of  heredity.  For  a  long  time  the  heredity  of 
the  insanity  and  that  of  general  paralysis  were  con- 
fused, and  some  authorities  still  hold,  with  Marce, 
that  these  two  affections  have  a  common  origin  and 
reciprocally  engender  each  other.  But  this  is  an 
error.  General  paralysis  has  its  source  in  an  heredity 
that  is  not  vesanic  but  cerebral  arthritic  or  congestive, 


GENEEAL  PAEALTSIS  (PAEALTTIC  INSANITY).    457 

as  has  been  shown  by  the  memoirs  of  Lunier,  Dou- 
trebente,  Baillarger,  Ball  and  Regis,  Lemoine  and 
Pierret.  We  may,  it  is  true,  meet  with  paretics,  the 
issue  of  insane  parents,  but  I  have  noticed  that  this 
particularity  shows  itself  in  the  vesanic,  remittent  or 
circular  form,  in  a  word,  that  it  is  imposed  upon  the 
general  paralysis  by  the  predominance  in  the  subjects 
of  the  paralytic  insanity  over  the  paralytic  dementia. 
I  have  many  times  consecutively  found  consan- 
guinity in  the  ancestors  of  general  paralytics. 

Sex, — It  has  always  been  remarked  that  general 
paralysis  is  more  frequent  in  the  male  sex,  and  also 
that  it  becomes  more  common  in  the  male  according 
as  we  rise  in  the  social  scale,  while  the  contrary  is 
true  of  the  female.  The  special  study  I  have 
given  to  the  disease  as  it  occurs  in  the  latter  has  en- 
abled me  to  reach  the  following  conclusions  which  are 
evidently  only  applicable  to  France :  (1)  In  the  pop- 
ulation of  the  rural  districts  general  paralj^sis  of  the 
insane  is  hardly  one  and  a  half  times  more  common  in 
men  than  in  women,  and  is  very  rare  in  either  sex ; 
(2)  among  the  laboring  population  of  the  large  cities 
it  is  three  times  more  common  in  men  than  in 
women,  and  is  relatively  frequent  in  both;  (3) 
in  the  higher  classes  of  society  it  is  nearly 
thirteen  times  more  frequent  in  men  than  in 
women,  and  is  very  common  in  the  former  while 
it  is  rare  in  the  latter.  In  proportion  to  the  whole 
number  of  the  insane,  it  was  found:  (1)  3  male 
paralytics  in  100  insane  males  in  the  country,  and 


458  INSANITY  WITH  DISEASES  OF  BRAIN. 

2.13  female  paralytics  in  every  100  female  insane; 
(2)  in  the  working  classes  of  the  large  cities  23  par- 
alytic males  in  100,  and  7.7  paralytic  females;  (3) 
finally,  in  the  higher  classes  of  society,  33.33  paralytic 
males  and  2.58  paralytic  females.  My  investigations 
were  made  on  7,552  insane  of  both  sexes,  including 
868  general  paralytics.  These  figures  approach  very 
nearly  those  of  MM.  Christian  and  Ritti  and  those 
of  M.  Planes.  It  is  also  generally  agreed  that  at  the 
present  time  the  increase  in  the  number  of  cases  of 
general  paralysis  is  much  more  noticeable  in  the 
female  than  in  the  male.  Of  late  years  there  have 
been  observed  a  certain  number  of  cases  of  conjugal 
general  paralysis^  i.  e.,  affecting  husband  and  wife 
at  the  same  time.  These  cases  seem  to  be  due  to 
the  reciprocal  syphilization  of  the  two  partners.  IsTot 
only  is  general  paralysis  less  frequent  in  the  female, 
but  it  presents  in  her  some  special  features.  It 
occurs  sometimes  in  the  prime  of  life,  sometimes,  on 
the  contrary,  later  and  especially  at  the  critical  age ; 
it  usually  takes  the  form  of  simple  paralytic  dementia, 
and,  lastty,  it  persists  for  a  longer  time. 

Professions. — It  is  the  liberal  professions,  the 
intelligent  classes  and  generally  those  that  labor 
most  with  their  brains  that  furnish  the  greatest  con- 
tingent to  general  paralysis,  at  least  in  men.  This 
has  been  recently  contested,  but  not  with  reason,  by 
M.  Arnaud.  It  is  in  fact  sufficient  to  fix  the  com- 
parative ratio  of  general  paralysis  to  the  other  forms 
of  insanity   in  the  different  establishments  for  the 


GENERAL  PARALYSIS  (PARALYTIC  INSANITY).    459 

insane,  to  demonstrate  that  this  proportion  is  higher 
in  the  private  than  in  the  public  institutions  of  the 
same  centre,  and  also,  what  is  very  significant,  that 
it  is  greater  in  the  private  asylums  of  the  provinces 
than  in  the  public  asylums  of  the  great  cities  and  of 
Paris.  In  the  higher  society  general  paralysis  is 
particularly  frequent  among  savants,  lawyers,  phy- 
sicians, politicians  and  business  men,  artists,  the 
military  (especially  the  officers). 

Occasional  Causes. — It  was  said  in  the  beginning 
of  the  remarks  on  etiology  that  the  most  potent  oc- 
casional cause  of  general  paralysis  is  syphilis.  This 
is  at  present  the  common  opinion  abroad,  as  is 
demonstrated  by  numerous  statistics  published  on 
all  sides.  In  France  this  is  not  the  case,  and  it  is 
hardly  two  years  since  I,  with  MM.  Morel-Lavallee 
and  Belieres,  was  almost  alone  in  supporting  this 
opinion.  It  must  be  said  that,  imbued  with  the  opin- 
ion that  syphilis  is  rare  in  general  paralysis  and  that 
it  can  only  produce  a  pseudo-form,  the  majority  of 
alienists  of  our  country  remained  indifferent  to  the 
question  and  abstained  from  any  personal  investi- 
gation in  this  direction.  Since,  however,  a  certain 
interest  has  been  aroused  in  the  matter,  this 
indifference  has  decreased,  and  already  many 
statistical  contributions  have  appeared  that  indicate 
that  when  one  takes  the  trouble  of  investigating  with 
the  needful  perseverance  it  is  found  that  syphilis 
exists,  as  I  have  held,  in  seventy  to  ninety  cases  out  of 


460  IXSANITT  WITH  DISEASES  OF  BRAIN. 

a  hundred  in  general  paralysis  (Bonnet  and  Anglade, 
Theses,  1891).  There  is  reason  to  believe  that  these 
statistics,  absoliiteh^  conclusive  as  they  are,  will  not 
delay  multiplying  and  that  in  a  short  time  a  very 
large  majority  of  French  alienists  will  be  fully  con- 
verted to  the  opinion  of  the  extreme  frequency  of 
syphilis  in  general  paralysis.  When  this  point  is 
reached,  and,  I  repeat,  I  have  no  doubt  in  regard  to  it, 
it  will  then  be  in  order  to  find  out  whether  general 
paralysis  is  a  disease  due  to  sjq^hilitic  lesions,  known 
or  unknown,  or  a  cerebral  entity  indirectly  devel- 
oped under  the  influence  of  syj)hilis ;  in  other  words, 
whether  it  is  a  syphilitic  or  a  Para-syphilitic  dis- 
order. The  question  is  now  at  this  stage  in  other 
countries;  the  chances  of  its  solution  will  only  be 
increased   when  we  take  it  up  ourselves. 

Aside  from  the  effect  of  syphilis,  which,  I  repeat, 
seems  to  be  preponderant,  the  other  occasional  causes 
of  general  paralysis  that  may  be  cited  are :  mental 
overstrain,  venereal  excesses,  and  the  various  intoxi- 
cations (nicotinism,  alcoholism,  saturnism,  pellagra, 
etc.),  which  themselves  especially  give  rise  to  pseu- 
do-general paralysis.  There  have  been  noted  also, 
as  more  or  less  active  causes,  the  effect  of  insolation 
and  of  sojourns  in  an  overheated  temperature,  the 
menopause,  the  suppression  of  hemorrhoids,  or  men- 
struation, cranial  injuries,  erysipelas  of  the  face, 
typhoid  fever,  and  lastly,  locomotor  ataxia  and  even 
diphtheria.  General  paralysis  does  not  favor  certain 
conditions   like    the  hysterical    tendency.     It  only 


GETTERAL  PARALYSIS  (PARALTTIC  INSANITY) .    461 

develops  in  such  but  rarely  and  when  it  exception- 
ally does  occur,  it  may  cause,  as  I  have  indicated,  a 
kind  of  antagonism  between  the  neurosis  and  the 
general  paralysis,  from  which  results  a  suspensory 
action  or  an  inhibitory  action  of  the  first  upon  the 
second.  It  is  also  this  antipathy  of  general  paralysis 
for  the  nervous  diathesis  that  forms,  according  to 
my  opinion,  one  of  the  principal  reasons  of  the  less 
frequence  of  general  paralysis  in  females. 

Treatment. — In  the  majority  of  cases  general 
paralysis  is  only  recognized  after  it  has  clearly  mani- 
fested itself.  It  is  therefore  nearly  always  impossi- 
ble to  institute  any  preventive  treatment. 

It  is  very  important  to  know  in  what  conditions 
of  general  paralysis  sequestration  becomes  necessary. 
Although  it  is  perhaps  impossible  to  establish  any 
fixed  rule  in  this  regard,  it  may  be  said  that  in  a 
general  way  confinement  is  needed  in  every  case 
attended  Avith  insanity,  whatever  may  be  its 
character,  maniacal  or  melancholic,  while  it  is 
not  absolutely  necessary  in  cases  of  simple  par- 
alytic dementia.  Sequestration  should  be  ad- 
vised especially  in  the  beginning  of  the  disorder, 
when  maniacal  excitation  exists,  as  it  is  in  this 
stage,  so  justly  called  by  Legrand  du  Saulle  the 
medico-legal  period,  that  the  patients  are  led  to 
commit  criminal  acts,  particularly  absurd  thefts,  or 
to  launch  out  in  adventurous  projects  and  imperil 
their  fortunes.     In  case  of  remissions  in  the  coi;rse 


462  IKSANITY  WITH  DISEASES  OF  BRAIN. 

of  the  disease,  it  is  needful  to  exercise  great  pru- 
dence as  to  setting  the  patients  at  liberty,  as  these 
remissions  are  commonly  only  temporary,  and  gen- 
erally dependent  on  the  sojourn  of  the  patients  in 
the  establishment  for  the  insane. 

The  medical  treatment,  properly  speaking,  of  gen- 
eral paralysis  includes  an  infinite  number  of  agents, 
none  of  which,  unfortunately,  has  up  to  this  time, 
afforded  any  really  favorable  results.  Those  from 
which  the  best  effects  have  been  obtained  are 
revulsives  applied  to  the  nucha,  especially  setons, 
permanent  vesication,  fine  cauterization  of  the  pos- 
terior cervical  region ;  unfortunately  these  are  efii- 
cient  only  early  in  the  disease  and  are,  moreover, 
borne  only  with  impatience  by  the  subjects.  Large 
and  repeated  paintings  with  iodine  may  also  be  tried 
as  recommended  by  Pritchard  Davies,  and  cautious 
suspension  with  a  modified  Sayre  apparatus  from 
which  good  results  have  been  obtained  by  M.  Fri^se 
and  myself.  As  to  irritant  frictions  of  the  scalp,  re- 
commended by  some  authors,  and  trepanation,  recent- 
ly tried  by  Shaw  and  Batty  Tuke,  they  should  be 
rejected  as  too  painful  and  without  any  real  action. 
The  same  is  the  case  with  mineral  waters,  sea  bath- 
ing, and  especially  hydrotherapy,  very  often  pre- 
scribed for  paralytics  in  the  early  stages  of  their 
malady,  but  which  are  hurtful  rather  than  useful  and 
too  often  have  only  the  effect  of  augmenting  the 
already  existing  tendency  to  cerebral  congestion. 
One  should  also  be  verv  cautious  as  to  abstraction  of 


GENERAL  PARALYSIS  (APOPLECTIC  DEMENTI a).  463 

blood  and  have  recourse  to  it  only  in  exceptional 
cases.  Some  authors  have  obtained  good  effects 
from  the  use  of  galvanic  currents  to  the  spinal  cord. 
In  the  way  of  medication,  antisyphilitic  treatment 
may  be  tried,  which  unfortunately  is  almost  always 
without  any  decided  effect,  the  iodide  of  potash  alone, 
in  moderate  doses  and  according  to  the  case,  sedatives, 
opium,  morphine,  veratrine,  hyoscyamine,  hyoscine, 
chloral,  sulfonal,  hypnal,  bromides,  digitalis,  er- 
gotine,  bitter  tonics,  iron  preparations,  but  especially 
the  evacuants,  which,  administered  at  proper  times, 
may  have  a  salutary  effect  on  the  course  of  the 
malady  and  may  even  prevent  the  congestive  com- 
plications. In  case  of  congestive  attacks,  sinapisms, 
repeated  purgative  enemas,  alkaline  bromides,  asso- 
ciated or  not  with  chloral,  and  finally  subcutaneous  in- 
jections of  ergotine,  recommended  by  Christian  and 
Girma,  should  be  employed.  Other  complications, 
such  as  refusal  of  food,  incoercible  agitation,  retention 
of  urine,  untidy  condition,  eschars  on  the  sacrum, 
incidental  diseases,  etc.,  etc.,  call  for  appropriate 
hygienic  and  therapeutic  attention. 

Apoplectic  Dementia, 

Circumscribed  lesions  of  the  brain  rarely  give 
rise  to  attacks  of  insanity  properly  so-called;  they 
oftener  produce  a  variety  of  dementia^  known 
under  the  name  of  apoplectic,  organic,  or  hemiplegic 
dementia,  to  differentiate  it  from  the  simple  or 
senile  forms.     Among  these  Jesions,  focal  softening 


464  UrSANITY  WITH  DISEASES  OF  BRAIN. 

is  the  one  that  produces  the  most  pronounced  mental 
symptoms. 

There  is  a  prodromal  period  of  more  or  less 
duration,  -wdth  symptoms  of  depression  or,  on  the 
other  hand,  of  excitement,  continual  desire  to  sleep, 
hallucinations,  particularly  visual  ones,  obtusion  of 
intelligence,  followed  by  hemiplegia  of  the  left  or 
right  side,  and  with  this  last  almost  always  aphasia. 
There  are  cases  where  the  mind  is  intact,  but  these 
are  rare,  and  the  patient  generally  continues  worse 
in  this  respect  after  the  attack;  sometimes  even 
the  mental  enfeeblement  becomes  progressive  and 
terminates  in  comj^lete  dementia,  with  which  may 
be  associated  more  or  less  acute  attacks  of  mania 
and,  even  more  probably,  melancholia. 

The  most  salient  clinical  feature  of  apoplectic  de- 
mentia is  the  tendency  to  emotional  disturbance 
which  is  particularly  shown  by  these  patients  in 
spells  of  crjdng  on  the  occasion  of  their  being  asked 
the  slightest  question.  According  to  M.  Luys,  this 
emotionality  is  more  marked  with  left  than  with 
right  hemiplegia,  and  he  recognizes  as  its  anatomical 
localization  a  lesion  of  the  cortex  which  corresponds 
with  the  upper  part  of  the  right  temporal  lobe  at 
the  inside  of  the  Sylvian  fissure. 

In  other  respects,  apart  from  bodily  symptoms, 
apoplectic  dementia  is  almost  analogous  to  senile 
dementia. 


LOCOMOTOE  ATAXIA.  465 

§n.     INSANITIES    CONNECTED    WITH    DISEASES 
OF  THE  SPINAL  CORD. 

(Locomotor  Ataxia.    Multiple  Sclerosis). 
Locomotor  Ata.xia. 

Since  attention  has  been  especially  called  to  the 
mental  state  of  tabetic  patients,  it  has  been  recog- 
nized that  mental  disorders  are  very  common  in  them. 
Usually  these  are  limited  to  simple  modifications 
of  the  intellect  and  character  that  show  themselves 
in  irritability,  distrustfulness,  low  spirits,  hypo- 
chondria, discouragement  and  tendency  to  suicide. 
In  some  cases,  and  this  may  occur  in  the  beginning, 
in  the  pre-ataxic  period,  sensory  disturbances  make 
their  appearance,  consisting  in  illusions  and  hallu- 
cinations, more  or  less  conscious,  principally  in  the 
domains    of    vision,    of    audition    and    of    general 

sensibility. 

The  psychic  disorders,  however,   are  not  always 

thus  limited  and  in  certain  cases  they  reach  genuine 

insanity.     Pierret  and  Rougier,  who  have    made  a 

special  study  of  this  insanity,  have  shown  that  it  is 

usually  a  lypemaniacal  condition,  with  vague  ideas 

of   persecution    and   confused   hallucinations.     The 

patients   accuse  persons  about   them  of  wishing  to 

poison   them,   of  burning  them,  they  complain    of 

hearing  insults,  of  having  a  bad  taste  in  their  food 

and   in  their  mouths,  and  of  feeling  tingling  and 

other  disagreeable  sensations  all  over  their  bodies. 

The  insanity  may  likewise  reveal  itself  under  the 


466       INSANITY  WITH  DISEASES  OF  SPINAL  COED. 

hypochondriacal  or  the  ambitious  form  as  in  general 
paralysis. 

Moreover,  tabes  may  be  accompanied  with  an 
intellectual  enfeeblement  which  occasionally  causes  a 
decided  difficulty  in  the  diagnosis  between  it  and 
general  paralysis.  There  are  also  cases,  as  we  have 
seen,  where  the  disorder  becomes  complicated,  so  to 
speak,  hybrid,  and  has  at  the  same  time  the  char- 
acters of  tabes  and  general  paralysis. 

Multiple  Sclerosis. 

Disseminated  sclerosis,  like  locomotor  ataxia,  may 
induce  a  condition  of  mental  failure  that,  on  account 
of  the  concomitant  tremor  and  embarrassment  of 
speech,  suggests  more  or  less  strongly  paralytic 
dementia.  The  facts  on  which  the  sometimes  diffi- 
cult diagnosis  is  to  be  based  have  been  already 
pointed  out.  The  less  constant  and  less  pronounced 
mental  weakness,  the  more  paralytic  than  ataxic 
embarrassment  of  speech,  and,  lastly,  the  intention 
tremor,  particularly  mark  multiple  sclerosis. 

It  is  rare  that  insanity  complicates  multiple  scle- 
rosis ;  on  the  other  hand,  rudimentary  psychic  disturb- 
ances, alterations  of  the  intelligence  and  changes  of 
character  are  rather  frequent,  but  do  not  offer  any 
point  of  special  interest. 


EPILEPTIC  INSANITY.  467 


§111.     INSANITIES   CONNECTED    WITH 
NEUROSES. 

(Epilepsy,   Htsteria,   Chorea,   Paralysis  Agitans,   Exophthalmic 

Goitre). 

The  mental  disorders  connected  with  the  neuroses, 
especially  those  complicating  epilepsy  and  hysteria, 
are  described  in  most  works  devoted  to  nervous  dis- 
eases and  are  consequently  known  to  all.  I  will  here 
only  review  their  principal  features. 

Epilepsy. 

{Epileptic  Insanity). 

We  here  have  to  notice  successively :  (1)  the  men- 
tal condition  of  the  epileptics ;  and  (2)  epileptic  in- 
sanity properly  so-called. 

1.  The  Mental  Condition  of  Epileptics. — 
When  epilepsy  is  not  engrafted  upon  some  mental  in- 
firmity, such  as  imbecility  or  idiocy,  epileptics  are 
often  very  intelligent.  It  is  only  in  the  long  run 
that  the  mental  faculties  are  altered  or  enfeebled. 
The  mental  disturbances  are  mainly  shown  in  the 
character.  In  regard  to  this  there  are  two  classes 
of  epileptics,  the  ones  sombre,  taciturn,  distrustful, 
quick  to  take  umbrage,  always  ready  to  quarrel,  to 
wound,  to  strike ;  the  others,  on  the  contrary,  are  obse- 
quious, obliging,  cajoling,  full  of  effusiveness  and 
goodness,  but  a  goodness  that  is  only  in  appearance 
and    that   hides   their   claws,       In   fact,    epileptics 


468        INSANITIES  COISIS'ECTED  WITH  NEUROSES. 

are  subject  to  fits  of  choler,  and  to  violent  and  furi- 
ous passions,  during  wMcli  they  are  not  masters  of 
themselves  and  would  readily  commit  homicide. 
They  are  often  vicious  and  have  perverse  instincts; 
they  are  gluttonous,  thieves,  masturbators,  falsifiers, 
etc.  They  often  have  a  tendency  to  a  morbid  piety, 
a  sort  of  outer  religiousness  mixed  with  hypocrisy 
which  is  never  so  marked  as  at  the  time  of  their  at- 
tacks. The  note  of  their  character  is  therefore  irri- 
tability. 

The  intellectual  disorders  often  remain  at  this 
stage,  either  constantly  or  during  the  intervals  of 
the  attacks,  which  themselves  may  be  accompanied 
or  followed  by  short  delirious  or  impulsive  attacks. 
Frequently  also  epileptics  become  fully  insane. 

2.  Epileptic  Insanity. — We  must  distinguish  in 
epileptic  insanity  the  insanity  of  the  intervals  from 
the  attacks  and  the  insanity  of  the  convulsive  crises. 

The  insanity  of  the  intervals  between  the  attacks 
is  rather  rare,  as  epileptics  are  not  ordinarily  in  a 
state  of  permanent  derangement,  the  insanity  is  gen- 
erally remittent  or  intermittent.  This  form  may 
occur,  nevertheless,  and  in  this  case  it  assumes  any 
form  whatever,  maniacal  or  melancholic,  sometimes 
melancholico-maniacal.  Its  special  characters  are 
that  it  is  most  frequently  accompanied  with  ideas  of 
persecution,  with  a  tendency  to  fits  of  passion,  and 
especially  to  irresistible  impulsions  (homicide, 
suicide),  and  finally  its  co-existence  with  terrifying 
hallucinations, 


JSPiLEPTlC  INSANITY. 


469 


The  insanity  connected  with  the  epileptic  attack 
itself  may  supervene :  A,  before;  B,  during;  and  C, 
after  the  attack. 

A. — The  pre-paroxysmal  epileptic  insanity  may 
show  itself  either  by  maniacal  excitement  or,  on  the 
contrary,  by  a  more  or  less  profound  depression, 
preceding  the  attack  for  several  days ;  but  it  is  much 
more  common  to  see  the  attack  itself  preceded  by 
hallucinations,  especially  of  sight  and  of  a  terrify- 
ing character.  These  hallucinations  may  be  of 
spectres,  of  wheels,  of  gigantic  objects,  of  wild 
beasts,  and  there  may  be  also  disagreeable  or  nau- 
seous odors,  or,  more  rarely,  auditory  hallucinations. 
As  a  rule  the  hallucination  reproduces  itself  in  con- 
secutive attacks.  It  is  very  common  to  see  the 
patients  make  always  the  same  gesture  or  pronounce 
the  same  words  at  the  moment  of  falling. 

Sometimes  the  fall  occurs  at  the  moment  the  hal- 
lucination appears ;  if  this  is  not  the  case  the  patient 
has  time  to  perform  some  insane  or  strange  action, 
or  to  give  himself  up  to  a  more  or  less  noisy 
delirium. 

B. — From  the  moment  the  cry  is  uttered  or  the 
attack  begins,  the  patient  loses  his  consciousness, 
and  the  characteristic  of  the  insanity  which  is  pro- 
duced with  the  epileptic  attack  is  the  absolute  loss 
of  consciousness  and  memory  that  attends  it.  This 
is  so  characteristic  a  symptom  that  it  is  not  met 
with,  with  the  same  evidences,  in  any  other  form  of 
insanity. 


4'J'O        l:^SANITIES  CONNECTED  WITH  XEUilOSES. 

During  the  attack  itself  the  insanity  cannot  occur 
except  when  the  convulsions  are  lacking  and  are  re- 
placed by  an  attack  of  insanity  (larvated  epilepsy). 
The  attack  of  insanity  in  this  case  commonly  consists 
in  a  violent  spell  of  mania,  lasting  for  one  or  for 
several  days,  and  succeeded  by  a  greater  or  less  de- 
gree of  prostration,  this  last  sometimes  going  so 
far  as  to  stupor.  But  still  oftener  the  attack  is  re- 
placed, by  a  sudden  instantaneous  impulsion,  nearly 
always  the  same,  to  homicide,  suicide,  arson,  exhi- 
bition of  the  genital  organs,  obscene  acts,  theft,  some 
wild  prank,  etc.,  etc.  On  each  new  occasion  the 
convulsions  are  replaced  by  an  impulse  almost 
invariably  the  same  and  producing  itself  under  the 
same  conditions.  These  cases  are  commoner  than  is 
generally  supposed,  since  epilepsy  is  not  suspected 
by  reason  of  the  absence  of  the  convulsions.  When 
he  comes  to  himself  the  patient  has  not  the  least 
consciousness  of  Avhat  he  has  done.  Frequently  it 
happens  that  he  starts  off  during  the  attack  and  is 
astonished  to  find  himself,  at  the  end  of  a  day  or 
two,  very  far  from  his  home,  without  knowing  how 
he  came  there  (comitial  ambulatory  automatism). 

C. — The  insanity  consecutive  to  the  attack  is  of 
all  varieties  the  most  common. 

It  may  manifest  itself  by  a  spell  of  melancholic 
depression,  sometimes  going  as  far  as  stupor,  with 
prostration,  immobility,  hebetude,  terrifying  hallu- 
cinations, etc.  It  may,  and  this  is  more  often  the  case, 
be  constituted  by  a  period  of  excitement,  sometimes 


EMLEPTIC  INSANITY.  i'^l 

very  acute,  with  loquacity,  choler,  spells  of  passion, 
impulsions  and  furor.  Usually  there  supervenes 
an  attack  of  acute  mania  that  breaks  out  sud- 
denly within  a  longer  or  shorter  period  after 
the  convulsions,  and  is  accompanied  by  a  noisy 
incoherent  delirium  or  sudden  impulsions  to 
destructiveness,  homicide,  or  arson.  This  is  the 
time  when  epileptics  are  most  dangerous.  They 
have  no  control  of  themselves  and  assume  a  terrible 
appearance.  With  flushed  and  swollen  countenance, 
staring  eyes,  and  strength  multiplied,  they  smash, 
destroy,  and  strike,  with  a  blind  fury,  everything 
that  is  before  them. 

These  spells  are  not  often  of  long  duration ;  after 
a  few  days  the  symptoms  gradually  subside,  to 
reappear  in  subsequent  attacks,  generally  with  the 
same  characters  and  peculiarities. 

Epileptic  insanity  terminates  after  a  longer  or 
shorter  time  in  mental  enfeeblement  and  dementia, 
which,  in  some  individuals,  may  assume,  more  or  less 
closely,  the  aspect  of  paralytic  dementia  in  its  cachec- 
tic period.  There  are  even  cases  where  the  diag- 
nosis may,  at  this  stage,  present  some  difficulty. 

Diagnosis. — The  diagnosis  of  epileptic  insanity  is 
not  usually  difficult  when  the  mental  symptoms  ac- 
company the  paroxysm.  It  is  sometimes  very  diffi- 
cult when  the  epilepsy  is  larvated. 

The  sudden  and  instantaneous  impulsions,  the 
repetition   of   the    same    symptoms    with    identical 


472       mSANITlES  CONNECTED  WITH  NEITROSES. 

peculiarities,  and  lastly  and  particularly  the  absolute 
unconsciousness  of  the  attack,  are  characteristic  of 
epileptic  insanit}". 

Peogxosis. — Very  grave.  We  are  ordinarily 
without  resources  in  epilepsia  vera. 

Treatment. — The  treatment  of  epileptic  insanity 
is  the  same  as  that  of  epilepsy  in  general.  It  con- 
sists therefore  in  the  prolonged  usage  of  sedatives 
and  antispasmodics. 

The  chief  indication  when  epilepsy  is  accompanied 
with  insanity  is  to  sequestrate  the  patients.  On  ac- 
count of  the  unconscious  and  generally  dangerous 
imjiulsion  to  which  they  are  so  often  subject,  it  is,  in 
fact,  very  imprudent  to  leave  them  at  liberty.  Even 
in  establishments  for  the  insane  they  almost  al- 
ways require  special  supervision,  and  as  we  are 
aware  the  [French]  law  requires  the  separation 
from  the  other  insane  of  epileptics  when  they  are  in 
excess  of  a  certain  number. 

Hystebia. 
{Hysterical  Insanity). 

As  in  the  case  of  epilepsy  we  must  here  examine 
successively  the  hysterical  mental  state  and  hysteri- 
cal insanity. 

1.  Mental  Condition  of  Hysteeia. — The 
future  hysterical  subjects  reveal,  in  a  mental  point 
of  view,  their  peculiar  characters  at  a  very  early  age. 


HYSTERICAL  INSANITY.  473 

They  are,  for  the  most  part,  young  girls  of  great 
mental  vivacity,  excessively  precocious,  impres- 
sionable, coquettish,  fond  of  attention,  skilled  in 
deception  and  falsehood,  subject  to  more  or 
less  marked  disorders,  especially  to  night  terrors, 
dreams,  nightmares,  and  often  also  to  palpitations 
and  anaemia.  Hysteria  once  established,  the  mental 
and  moral  condition  of  its  subjects  is  characterized 
principally,  as  regards  the  intellect,  by  an  excessive 
mobility  so  that  the  patients  have  no  spirit  of  order, 
no  fixed  idea,  and  while  able  to  show  on  occasion, 
a  cultivated,  brilliant  and  often  caustic  wit,  they  are 
absolutely  unfit  to  follow  any  serious  business. 
With  this  there  exists  a  very  marked  tendency  to 
contradiction  and  controversy,  and  also  to  imitation, 
and  to  paradoxical  ideas  and  to  opinions  that  may 
distinguish  them  and  make  them  conspicuous.  Mor- 
ally, their  condition  is  the  same.  Their  character  is 
bizarre^  capricious,  fantastic,  mobile  to  excess,  their 
sensibility  very  lively  and  out  of  proportion  to 
occurrences ;  there  are  perpetually  sudden  changes  of 
the  feelings  and  affections,  ill-judged  enthusiasms ; 
duplicity,  falsehood,  abominable  deceitfulness,  sud- 
den and  violent  propensities  to  the  most  perverse  and 
criminal  actions,  as  well  as  to  acts  of  humanity 
and  bravery  of  the  most  praiseworthy  kind;  they 
exhibit  a  constant  desire  for  movement,  for  being  ob- 
served, of  keeping  themselves  before  their  neighbors, 
the  public  and  the  press,  and  consequently  of  caus- 
ing surprises  or  of  weaving  the  threads  of  an  inex- 

Mbnt.  Med.— 30. 


4.74       rN"SA2?ITIES   CONISTECTED  "WITH  ISTEUEOSES. 

tricable  romance:  such  are  the  chief  characters  of 
the  moral  condition  of  the  hysterical  subjects,  whicli 
may  be  summed  up,  that  in  them  everj'thing  is  mo- 
bility and  contrast:  sentiments,  affections,  instincts 
and  acts.  As  regards  the  sexual  tendencies  that 
have  been  considered  a  pathognomonic  sign  of  hys- 
teria, it  must  be  admitted  that  their  exaggeration 
is  not  constant,  and  that  here  also  there  is  mobility 
and  excess,  sometimes  in  one  direction,  sometimes  in 
another. 

All  these  disturbances  which  reveal,  taken  alto- 
gether, an  absolute  lack  of  equilibrium  of  the 
psychic  personality  in  the  patients,  and  which  are 
exaggerated  almost  always  by  the  events  of  life, 
more  especially  the  great  processes  of  the  sexual  life, 
such  as  pregnancy,  menstruation,  the  menopause, 
may  in  certain  cases  end  in  confirmed  insanity. 

Hysterical  Insa^tity. — As  in  epilepsy,  we  have 
to  distinguish  in  hysteria  the  attacks  of  insanity 
connected  with  the  paroxysms,  and  that  of  the  in- 
tervals. The  first  are  commonly  known  under  the 
name  of  hysterical  delirium,  the  second  constitutes 
hysterical  insanity,  properly  so-called. 

A.  Hysterical  Delirium. — Hysterical  delirium, 
that  is,  the  attack  of  temporary  insanity,  connected 
with  ther  convulsive  attack,  may  appear  before, 
during  or  after  the  paroxysm. 

When  before  the  attack,  it  shows  itself  the  few 


HYSTERICAL  INSANITY.  475 

days  preceding  by  a  change  of  character,  by  an  ex- 
cessive tendency  either  to  excitement  or  to  depres- 
sion. As  the  crisis  approaches  these  phenomena 
become  exaggerated  and  there  is  added  to  them  a 
veritable  agitation  with  confused  ideas,  incoherent 
propositions,  disordered  actions,  perhaps  torpor, 
often  accompanied  v^Mh  hallucinations  of  sight  and 
of  hearing,  or  with  false  tactile  sensations  which  oc- 
casionally are  unilateral.  When  the  paroxysm  com- 
mences there  is  produced  a  sort  of  arrest  and  these 
symptoms  disappear. 

During  the  attack  the  delirium  manifests  itself 
either  in  the  beginning  or,  rather,  toward  the  close, 
by  a  sort  of  acted  dream  that  begins  suddenly  and 
reveals  itself  in  a  rapid  and  changing  succession  of 
the  most  various  thoughts  uttered  aloud  in  the  form 
of  an  unconnected  monologue  of  images;  this  delir- 
ium is  the  result  of  the  multiple  hallucinations  ex- 
perienced by  the  patient  at  the  moment  and  it  causes 
the  gestures,  attitudes  and  acts  in  accordance  with 
the  conceptions  that  compose  it.  The  crisis  over 
the  reason  returns. 

The  hysterical  attack  itself  may  be  replaced  by  a 
more  or  less  acute  phase  of  delirium  of  the  maniacal 
or  melancholic  type. 

After  the  paroxysm  there  is  usually  a  period  of 
excitement  with  loquacity  and  noisy  laughter,  or 
more  often  a  period  of  torpor  and  depression 
with  more  or  less  complete  mutism,  tears  and 
sobbing. 


476        INSAinTIES  CONNECTED  WITH  NEUEOSES. 

B.  Htstekical  Insanity. — Hj^sterical  insanity, 
proper,  is  that  whicli  occurs  in  hysterical  subjects, 
apart  from  the  convulsive  attacks,  under  the  influ- 
ence of  any  exciting  cause  whatever,  either  moral  or 
physical,  and  sometimes  without  any  apparent  cause. 
According  to  some  authorities  it  is  an  insanity  of 
degeneracy.      (Colin,  1891). 

This  insanity  may  show  itself  under  the  form  of 
more  or  less  acute  attacks  of  mania  or  melancholia 
with  their  usual  symptoms.  It  is  rather  more  com- 
mon to  see  it  assume  the  reasoning  type.  This 
marked  predilection  of  hysterical  insanity  for  the 
reasoning  variety  explains  its  principal  characteris- 
tics, which  are :  the  semi-consciousness  of  the  patients 
of  their  condition;  the  limitation  of  their  delu- 
sive conceptions,  of  whatever  nature,  erotic,  mystic, 
hypochondriacal,  of  pride,  or  of  persecution,  to  the 
sphere  of  things  possible  and  realizable,  also  the  mo- 
bility of  these  conceptions ;  the  predominance  of  the 
psychic  disorders  in  the  passional  sphere,  in  the  in- 
stinct and  in  the  acts,  thus  giving  rise  to  affective 
perversions,  to  calumnies,  to  false  accusations  and 
denunciations,  simulations  of  suicide  or  of  violation, 
foolish  erotic  and  platonic  affections,  fits  of  passion, 
and  finally  to  morbid  impulsions  to  theft,  incendiar- 
ism, suicide  and  homicide,  that  alwaj^s  have  the  ear- 
marks of  the  hysterical  basis  on  which  they  are 
superadded. 

Less  frequently  there  is  produced  an  attack  of 
stupor,  with  mutism,  refusal  of  food,  irresistible  ten- 
dency to  suicide,  etc. 


CHOEEIC  INSANITY.  477 

The  diagnosis  of  hysterical  insanity  generally 
offers  no  difficulties,  as,  even  when  the  convulsive 
attacks  are  lacking,  the  stigmata  of  the  neurosis  are 
so  numerous  and  varied,  that  enough  of  them  are 
always  existing  to  demonstrate  the  true  origin  of 
the  mental  alienation. 

The  prognosis  is  comparatively  favorable,  partic- 
ularly when  the  attacks  of  insanity  are  plainly  acute. 
Recovery  then  takes  place,  according  to  Moreau  (de 
Tours) ,  in  one-half  of  the  cases.  The  reasoning  type 
of  insanity  is  much  more  serious  and  much  more  tena- 
cious. It  must  be  remembered,  finally,  that  when 
hysterical  insanity  is  prolonged,  it  terminates  almost 
invariably,  after  a  longer  or  shorter  time,  in  de- 
mentia. 

As  regards  treatment,  it  is  much  the  same  as  that 
of  hysteria  in  general,  and  like  that  it  calls  for  the 
employment  of  the  alkaline  bromides,  opium,  mor- 
phine, antispasmodics,  hydrotherapy,  etc.  Confine- 
ment is  often  necessary  on  account  of  the  predomin- 
ance of  the  psychic  disorders  in  the  sphere  of 
action. 

Chorea. 

{Choreic  Insanity). 

If  disturbances  of  the  intelligence  are  common  in 
epilepsy  and  hysteria,  they  are,  on  the  contrary,  much 
more  infrequent  in  chorea,  where  they  are  met  with 
in  only  two-thirds  of  the  cases  according  to  Marc6. 
The  age   and  sex  of   the  patients,  as  well  as  the 


478         LN-SANITIES  CONaSTECTED  WITH  NEUROSES. 

acuteness  or  intensity  of  tlie  neurosis,  seem  not  to  have 
any  special  action  on  the  production  of  these  troubles, 
for  which  only  an  original  predisposition  appears  to 
be  accountable.  However  this  may  be,  it  is  necessary 
to  study  both  the  mental  condition  and  the  insanity 
of  chorea. 

The  Mextal  Coxdition  or  Choreics. — In  an 
intellectual  point  of  view  the  chief  disturbances  met 
with  in  choreic  subjects  are  the  defects  of  memory 
and  attention,  the  mobility  of  the  ideas,  the  lack  of 
consistency  in  the  recollections,  the  mental  hebetude. 
What  however  is  most  characteristic  in  the  patients, 
in  this  point  of  view,  is  the  existence  of  special  hallu- 
cinations on  which  Marce  has  justly  laid  stress. 
These  almost  always  involve  vision,  very  rarely  taste, 
smell,  tact,  or  hearing.  They  are  especially  common 
in  females,  and  rarely  appear  before  fourteen  years 
of  age.  They  occur  chiefly  in  the  evening,  in  the 
drowsy  condition  between  waking  and  sleeping,  and 
are  very  often  continued  in  dreams. 

They  always  are  of  a  painful  nature,  terrifying, 
fantastic,  and  consist  in  scenes  of  death,  burials,  of 
hell,  butcheries,  and  conflicts,  which  pass  before  the 
subject  as  in  a  kaleidoscope  (kaleidoscopic  hallucin- 
ations). They  cause  the  patients  much  discomfort 
and  arouse  a  terror  of  going  to  sleep  that  causes  them 
to  keep  awake  and  to  try  to  hide  themselves  under 
the  coverings.  When  these  hallucinations  are  con- 
tinued  into    the    dreams    they    cause    awakening, 


CHOEEIC  rN"SANITT.  479 

starting,  cries  and  nightmares.  This  symptom  is 
sometimes  a  premonitory  sign  occurring  many  days 
prior  to  the  appearance  of  the  convulsive  movements ; 
sometimes,  and  more  commonly,  it  appears  at  the 
time  the  choreic  paroxysms  show  themselves.  It 
may  persist,  moreover,  for  many  months.  Its  dis- 
appearance is  generally  a  favorable  prognostic ;  while, 
on  the  other  hand,  its  exacerbation  may  become  the 
starting-point  of  a  true  maniacal  delirium.  Morally, 
the  predominant  disturbances'  in  chorea  affect  the 
character,  which  is  modified  and  altered.  The  major- 
ity of  the  patients  become  impressionable,  emotional, 
irascible,  impatient,  disputative,  passionate,  and  even 
violent.  These  disorders  are  more  marked  in  patients 
whose  phonator  muscles  are  involved  in  the  chorea, 
and  who  find  food  for  their  irritability  in  the  super- 
fluous efforts  they  make  to  express  themselves  dis- 
tinctly. 

Choreic  I]S"Sanity. — Choreic  insanity,  which  is 
rather  rare,  may  appear  in  either  the  maniacal  or 
the  melancholic  form. 

The  maniacal  form  shows  itself  in  attacks  that 
sometimes  appear  in  the  beginning  of  the  disorder, 
but  more  often  only  occur  many  days  after  the  ap- 
pearance of  the  convulsive  movements.  In  either 
case  it  may  take  on  the  character  of  acute  mania 
with  incoherent  delirium,  noisy  excitement,  hoarse 
inarticulate  cries,  disconnected  words,  or  it  may 
even  present  itself  under  the  form  of  acute  febrile 


480         INSAlflTIES  COIS^NECTED  WITH  NEUEOSES. 

delirium  with  pulse  at  120,  hot  skin,  dry  tongue, 
mumbling,  sputation,  violent  and  uncontrollable  agi- 
tation, and  sometimes  even  choreic  convulsions 
coming  on  in  spells. 

The  melancholic  form  sometimes  appears  as  a 
delusional  melancholia,  based  on  already  existing 
hallucinations  and  consequently  accompanied  with 
ideas  of  persecution  and  poisoning,  anxiety,  tend- 
encies to  sitiophobia  and  suicide,  sometimes  as 
stuporous  melancholia  with  profound  hebetude,  fits 
of  weeping,  immobility,  terrors,  and  amnesia. 

The  above  description  applies  especially  to  ordi- 
nary or  Sydenham's  chorea.  But  the  other  forms  of 
chorea  may  also  be  attended  with  psj^chic  disorders 
(Digoy,  Thhes  de  Paris,  1890). 

Thus  in  the  rhythmic  choreas  ma}'^  be  mentioned 
the  chorea  of  pregnancy  which  is  sometimes  associated 
with  a  maniacal  type  of  insanity,  and  especially 
hereditary,  or  Huntington's  chorea,  which  very  fre- 
quently gives  rise  to  a  progressively  increasing  en- 
feeblemeiit  of  the  mental  faculties,  accompanied  in 
some  cases  with  melancholia,  suicidal  ideas,  or  more 
often  irritability  and  violence,  less  frequently  ideas 
of  persecution  and  of  grandeur,  and '^hallucinations 
(Charcot,  Clarence  King,  Peretti,  Digoy).  Chorea 
of  old  age  also  terminates  in  dementia  in  the  major- 
ity of  cases.  As  to  the  mental  disorders  of  hemi- 
chorea,  they  are  analogous  to  those  of  hemi2:)legic 
dementia,  and  have  the  same  cause. 

In  the  rhythmic  or  systematic  choreas  the  moral 


CHOREIC  INSANITY.  481 

and  mental  disturbances  assume  the  excessive  mobil- 
ity pathognomonic  of  the  mental  condition  of  hys- 
teria. There  may  also  be  a  true  insanity,  mania  or 
melancholia,  with  visual  and  auditory  hallucinations 
and  also  hallucination  of  the  general  sensibility, 
usually  temporary  and  following  the  attacks  but  sus- 
ceptible also  of  being  continued  during  the  intervals 
and  then  assuming  the  reasoning  type  of  hysterical 
insanity. 

The  pseudo-choreas  such  as  the  tic  de  Salaam 
which  belongs  rather  to  epilepsy  and  is  frequently 
seen  in  the  lower  grades  of  degeneracy,  and  the  con- 
vulsive tics  (Gilles  de  la  Tourette's  disease)  already 
alluded  to  under  the  head  of  neurasthenia,  need  only 
be  mentioned  here. 

The  peculiar  convulsions  that  accompany  these 
various  conditions  of  insanity  leave  no  doubt  as  to 
their  nature,  hence  the  diagnosis  of  choreic  insanity 
presents  usually  no  difficulties. 

The  prognosis  is  variable.  While  not  serious 
when  the  psychic  troubles  do  not  exceed  those  we 
have  indicated  as  the  mental  condition  of  chorea,  or 
when  the  insanity  is  confined  to  an  attack  of  acute 
mania  or  mild  melancholia,  it  becomes  very  grave  in 
the  stuporous  form  or  in  that  of  acute  delirium. 

The  treatment  is  that  of  the  neurosis,  and  there- 
fore consists  chiefly  in  cold  affusions,  sulphurated 
baths,  valerian  and  antispasmodics,  prolonged  warm 
baths,  opium  in  increasing  doses,  strychnia,  iron  and 
tonics.  In  case  of  acute  excitement,  sequestration 
is,  moreover,  almost  always  necessary. 


482        INSANITIES  CONNECTED  WITH  NEUEOSES. 

Paralysis  Agitans. 

M.  Ball,  and  still  more  recently  other  authors, 
Parant,  Bergerio,  Roger,  and  others,  have  given  es- 
pecial attention  to  the  mental  troubles  attending 
paralysis  agitans.  It  results  from  their  studies  that 
while  nearly  all  the  subjects  of  this  ailment  have 
more  or  less  marked  disturbances  of  the  ideas,  char- 
acter and  feelings,  these  may  in  some  cases  attain  to 
the  dimensions  of  real  insanity.  This,  in  such  cases, 
appears  usually  under  the  melancholic  form,  either 
with  the  symptoms  of  delusional  melancholia  accom- 
panied with  anxiety,  ideas  of  persecution  and  poison- 
ing, and  with  hallucinations,  or  with  those  of  stupor ; 
the  insanity  is  not  permanent,  and  usually  follows 
the  changes  of  the  malady  itself,  generally  disap- 
pearing whenever  the  tremor  ceases.  It  may  be 
added  that  the  majority  of  the  cases  of  paralysis 
agitans  terminate  in  dementia. 

Exophthalmic  Goitre. 

It  has  long  been  known  that  sufferers  from  ex- 
ophthalmic goitre  are  erratic,  irritable,  changeable 
and  unequal  in  their  characters  and  mode  of  life. 

In  a  very  interesting  lecture  recently  published 
{Bull,  inediccd^  1890),  Professor  Peter  has  called 
special  attention  to  a  symptom  that  approaches  to 
being  a  cajDital  and  pathognomonic  one  in  this  dis- 
ease: a  morbid,  neuropathic  emotivity,  revealing 
itself  not  only  in  the  most  intense  psychic  sensibil- 


EXOPHTHALMIC  GOITRE.  483 

ity  and  unrest,  but  also  by  very  marked  somatic 
phenomena  in  the  domain  of  the  great  sympathetic ; 
palpitations,  choking  sensations,  precordial  pain, 
flushes  of  heat  and  pallor,  spells  of  sweating  and 
of  diarrhoea,  etc.,  etc.  It  is  easy  to  see  from  this 
short  enumeration  that  the  predominating  neurotic 
symj)toms  in  Basedow's  disease  very  closely  resemble 
those  of  neurasthenia.  In  fact  I  believe  that  neu- 
rasthenia, chiefly  in  its  emotional  form,  accompanies 
many  cases  of  exophthalmic  goitre;  and  I  have 
found,  on  the  other  hand,  that,  in  a  large  number  of 
obsessional  neurasthenias,  the  disorder  commenced 
at  puberty  with  palpitations,  and  that  it  was  later 
complicated  with  swelling  of  the  neck  and  prom- 
inence of  the  eyes,  recalling  more  or  less  clearly  the 
malady  of  Basedow.  These  facts  show  that  an  in- 
timate relation  exists  between  these  two  diseases,  and 
it  will  be  of  interest  to  follow  out  further  the  inves- 
tigations as  to  this  point. 

While  exophthalmic  goitre  is  never,  so  to  speak, 
without  some  mental  and  moral  disturbances,  it  is 
accompanied  in  some  cases  with  actual  insanity. 

This  insanity,  as  has  been  remarked  by  M.  Ray- 
mond Martin  {Theses  de  Paris,  1890),  may  supervene 
either  after,  or  with,  or  even  before  the  appearance 
of  the  exophthalmic  goitre. 

It  follows  from  numerous  facts  published  of  late 
years  by  Savage,  Meynert,  Charcot,  Rendu,  Ballet, 
Joffroy,  Debove,  and  Landouzy,  and  summed  up  by 
M.  Martin  in  his  thesis,  that  the  types  of  insanity 


484         INSANITIES  CONNECTED  WITH  NEUROEES. 

observed  in  Basedow's  disease  are  rather  variable. 
Acute  maniacal  conditions  seem  nevertheless  to  pre- 
dominate ;  but  we  also  meet  with  hypochondriacal  or 
anxious  melancholia,  and  especially  with  vaguely 
systematized  delusions  of  persecution  or  mj'-sticism, 
with  almost  constant  visual  and  auditory  hallucina- 
tions such  as  are  observed  in  hysteria. 

Exophthalmic  goitre  is,  in  fact,  very  frequently 
connected  with  this  neurosis ;  which  makes  it  impos- 
sible to  state  precisely  to  which  of  the  two  aifections 
the  insanity  is  to  be  attributed  {Soc.  mM.  des 
hopitaux^  1890). 

As  M.  Martin  well  says,  in  these  mixtures  it  is 
hard  to  state  the  part  that  is  played  by  one  or  the 
other  morbid  condition.  Moreover,  exophthalmic 
goitre,  like  hysteria,  has  its  origin  in  a  neuropathic 
heredity,  and  it  is  not  demonstrated,  as  Avas  said 
above  in  speaking  of  hysteria,  that  there  are  not 
direct  relations  existing  between  these  different  ex- 
pressions of  the  same  diathesis. 


Cbaptet  ^n. 

INSANITIES   CONNECTED   WITH    INTOXI- 
CATIONS. 

(Toxic  Insanities). 

I.     ALCOHOLISM. 

(Inebbiett,  Alcoholic  Insanity,  Alcoholic  Dementia.   ALOoHoiiic 
Pseudo-Genekal  Paralysis). 

The  term  alcoholisTn,  originated  in  1856  by- 
Magnus  Huss,  is  applied  to  the  whole  range  of  dis- 
orders caused  by  poisoning  by  alcoholic  liquors. 
According  as  the  toxic  action  is  sudden  or  prolonged, 
the  alcoholism  is  called  acute  or  chronic. 

The  psychic  disorders  of  alcoholism,  the  only  ones 
that  will  occupy  us  here,  may  show  themselves  in 
either  acute  or  chronic  alcoholism.  We  find  them 
occurring  by  preference,  in  subjects  who  are,  by 
heredity,  profession,  or  conditions  of  debility,  pre- 
disposed to  cerebral  "or  vesanic  disorders  and  who 
are  given  to  immoderate  use  of  alcohols  of  bad  qual- 
ity or  liquor  of  absinthe  ( absinthism) . 

The  most  of  the  states  of  mental  alienation  may 
be  met  with  in  alcoholism,  from  ordinary  drunken- 
ness, the  incomplete  and  temporary  loss  of  reason, 
to  simple  dementia  and  paralytic  dementia.  Those 
that  are  most  common,  however,  are  acute  general- 
ized insanities  of  the  maniacal  or  melancholic  type. 


486  TOXIC  i:N"SAiaTiES. 

On  each  of  these  conditions  of  insanity  certain  special 
characters,  more  or  less  striking,  are  impressed  by 
alcoholism,  which  compel  us  to  pass  them  in  review. 
We  will  therefore  describe  successively :  (1)  drunk- 
enness; (2)  acute  alcoholic  insanitj^  (maniacal  or 
melancholic)  with  its  subacute  and  hyperacute  vari- 
eties; (3)  simple  alcoholic  dementia;  (4)  alcoholic 
pseudo-general  paralysis. 

1. — LSTEBRIETY. 

Inebriety  comprises  three  distinct  periods.  The 
first  is  that  of  excitation ;  it  is  characterized  by  an- 
imation of  the  face  and  expression,  increase  of  the 
pulse,  the  perspiration,  the  urinary  secretions  and 
especially  by  a  feeling  of  well  being,  wdth  loquacity 
and  expansive  tendencies.  Those  w^ho  are,  as  they 
say,  merry  in  their  liquor,  are  full  of  life  and  spirit, 
of  gaiety  and  movement;  those  who  are  maudlin  in 
their  cups  are  depressed,  inclined  to  relate  their  mis- 
fortunes ;  weep  and  lament  without  motive ;  some 
become  benevolent,  tender,  affectionate,  much  in- 
clined to  erotic  manifestations ;  others  become  iras- 
cible, easily  disturbed  and  have  a  marked  tendency 
to  quarrel  and  come  to  blows.  At  this  stage  the 
man  still  is  semi-conscious  of  his  condition  and  re- 
tains the  power  of  self-control,  at  least  to  a  certain 
extent.  But  there  exists  already  a  sort  of  moral 
anaesthesia;  nothing  shocks  him. 

The  second  stage  or  drunken  period  is  character- 
ized by  more  pronounced   disturbances.     There  is 


ALCOHOLIC  INSANITY.  487 

no  longer  merely  exaltation,  but  also  perturbation 
of  the  intelligence;  the  ideas  are  confused,  uncon- 
secutive  and  excessively  variable ;  the  language  is  in- 
coherent and  disconnected;  the  tongue  is  thick,  the 
speech  embarrassed,  sexual  power  usually  abolished, 
the  walk  vacillating,  and  the  sensibility  much 
obtunded.  Simultaneously  there  exist  sensory  dis- 
turbances, such  as  confusion  of  vision,  diplopia,  tin- 
nitus, illusions  of  taste  and  general  sensibility,  and 
occasionally  true  delusions  with  impulsions. 

The  third  period  is  the  comatose  stage.  It  is 
marked  by  long  and  profound  sleep,  with  profuse 
sweating,  during  which  the  individual  is  exhausted, 
inert  and  completely  unconscious.  On  awaking 
there  is  more  or  less  pronounced  general  malaise^  an 
uncomfortable  feeling  of  lassitude,  a  feverish  thirst, 
great  dryness  of  the  mouth,  and  severe  headache. 

Besides  this  simple  inebriety  as  we  call  it,  there 
are  other  more  serious  forms,  notably  the  convulsive 
form,  described  by  Percy,  and  amnesic  inebriety. 

2. — Alcoholic  Insanity. 

Alcoholic  insanity  may  present  itself  under  either 
the  maniacal  or  the  melancholic  form. 

As  regards  its  intensity,  it  is  met  with  in  three 
different  degrees:  a. — the  subacute  attack;  b. — the 
acute  attack,  properly  so-called;  c. — the  hyperacute 
attack.  Whatever  the  intensity,  the  attack  of  alco- 
holic insanity  is  liable  to  occur  either  in  acute  alco- 


488  TOXIC  INSANITIES. 

/ 

holism  following  a  sudden  and  transient  intoxication, 
or  at  any  moment  whatever  in  the  course  of  a  chronic 
poisoning.  Its  appearance  may  follow  great  excesses 
{delirium  a  potu  nhnio)  as  well  as,  on  the  other 
hand,  the  suppression  of  habitual  stimulation  {delir- 
ium a  potu  suspenso).  It  is  also  a  common  thing 
to  see  the  attack  of  insanity  occur  suddenly  as  the 
effect  of  a  moral  or  physical  shock  (moral  or  physical 
traumatism),  and,  especially  of  an  intercurrent  dis- 
order. Thus  alcoholic  delirium  develops  in  a  pneu- 
monia for  example,  or  after  surgical  operations 
(nervous  delirium  of  the  wounded).  Any  trifle  is 
enough  in  individuals  intoxicated  and  saturated  with 
alcohol,  to  call  up  or  awaken  the  cerebral  disorder. 

A.  Subacute  Insanity. — The  most  frequent 
form  of  insanity  in  alcoholism  is  the  subacute  type 
that  ordinarily  occurs  as  a  transient  episode  in  the 
course  of  chronic  alcoholic  poisoning.  Its  manifest- 
ation is  almost  always  of  the  melancholic  type. 

The  attack  usually  begins  with  disturbances  of 
sleep  which  become  unsatisfactory  and  troubled  with 
dreams.  Lasegue,  whose  description  I  reproduce, 
says  that  the  subject  of  alcoholism,  before  becoming 
insane  begins  by  sleeping  ill,  and  that  his  delirium 
is  only  a  waking  dream  of  the  day  that  follows,  as  a 
consequence,  a  sleeping  dream  of  the  night,  and 
continues  not  only  in  a  psychic  sense,  but  also 
chronologically.  The  dreams  of  these  subjects  are 
especially  dreams  of  action,  drawn  from  familiar  sub- 


ALCOHOLIC  INSANITY.  489 

jects  of  events  of  the  time,  dramatic  displays,  and 
in  which  hallucinations  of  sight  play  the  principal 
part.  A  time  arrives  when  these  dreams  prolong 
themselves  into  the  waking  moments,  and  this  it  is 
that  constitutes  the  alcoholic  delirium.  This  painful 
change  from  sleeping  to  waking  follows  an  excessive 
agitation  preventing,  like  a  nightmare  pushed  to  ex- 
tremes, the  possibility  of  sleep,  or  some  external  ex- 
citation, or  any  cause  whatever.  The  passage  from 
dormant  to  waking  delirium  is  made  without  trans- 
ition, the  insanity  does  not  follow  some  distance 
after  the  dream,  it  becomes  simply  its  intensification 
and  maximum.  The  condition  as  regards  the  nature 
of  the  abnormal  phenomena  is  the  same,  the  delusions 
are  the  continuation  of  the  dreams.  The  same  fan- 
tastic combinations  and  thrilling  situations,  the 
same  strange  or  sinister  adventures,  the  same 
disordered  and  changing  scenes  occur.  In  the  alco- 
holic insanity,  as  in  the  dream,  visual  hallucinations, 
that  usually  assume  a  terrifying  character  and  con- 
sist mainly  in  visions  of  animals,  thieves,  assassins, 
battles,  fires,  deaths,  etc.,  play  a  chief  part  and  to 
the  almost  complete  exclusion  of  any  others.  Audi- 
tory hallucinations,  in  fact,  are  reduced,  as  a  rule,  to 
merely  confused  impressions,  sounds  of  steps  or  blows, 
muffled  cries  and  a  few  interjected  phrases.  On  the 
other  hand,  like  all  dreamers,  the  alcoholic  subject 
is  constantly  undergoing  some  physical  and  moral 
change,  during  his  attack.  His  speeches  are  lengthy 
but  made  up  of  detached  phrases  without  logical  con- 

Ment.  Med.— 31. 


490  TOXIC  INSANITIES. 

nection.  Mere  facts  without  reflections  and  still 
less  of  wonder  and  criticism.  What  is  past  is  past, 
and  that  is  all.  A  last  peculiarity  common  to  dreams 
and  alcoholic  delirium  is  the  possibility  of  these  con- 
ditions being  suddenly  and  temporarily  suppressed 
by  shaking  the  dreamer  or  the  patient  and  accom- 
panying the  act  with  some  strong  expression. 

Basing  himself  on  these  peculiarities  Las^gue  is 
able  to  say  that  subacute  alcoholic  insanity  is  not  an 
insanity  but  a  dream. 

With  these  psychic  symptoms,  to  which  must  be 
added  the  rather  frequent  tendency  to  suicide,  are 
joined  the  habitual  bodily  symptoms  of  alcoholism, 
such  as  generalized  tremor,  cramps,  formications, 
dyspeptic  disorders,  analgesia  or  hyperaesthesia  of 
the  limbs,  convulsive  hysteriform  or  epileptiform 
accidents,  etc.,  etc. 

The  subacute  form  of  alcoholic  insanity  is  of  vari- 
able but  generally  of  short  duration,  at  least  when 
the  patient  stops  drinking.  It  is  rare  that  there  is  not 
an  amelioration  after  five  or  six  days ;  little  by  little 
the  dream  disaj)pears  and  the  reality  returns.  Just 
as  the  loss  of  sleep  marked  the  beginning  of  the  dis- 
order, so  its  return  marks  its  termination. 

B.  Acute  Insanity. — Acute  alcoholic  insanity 
occurs  under  the  same  conditions  as  the  subacute 
form,  and  it  manifests  itself  sometimes  under  the 
form  of  melancholia,  sometimes  and  more  often,  that 
of  mania.  ,  The  melancholic  variety  differs  from  that 


ALCOiaoLiC  INSANITY.  491 

of  the  subacute  type,  only  in  its  higher  degree  of 
intensity.  It  is  preceded  by  prodromata  such  as 
feelings  of  malaise,  oppression,  gastric  uneasiness, 
cephalalgia ;  the  insomnia  is  more  complete,  the  hal- 
lucinations more  terrifying,  the  tearfulness  becomes 
a  genuiu  e  panophobia,  and  the  patients  believe  them- 
selves surrounded  by  enemies,  ferocious  beasts, 
flames,  cadavers,  they  fly  in  affright  and  are  the 
prey  of  unspeakable  terror.  There  is  added,  more- 
over, to  this  condition,  a  true  delirium  that  revolves, 
as  a  rule,  around  ideas  of  hypochondria  and  persecu- 
tion especially.  The  victim  of  alcoholism  believes 
he  is  full  of  worms,  rotten,  that  he  has  no  stomach  or 
head,  that  he  is  dead,  that  people  are  mocking  him, 
his  wife  deceives  him,  that  it  is  sought  to  poison 
him,  that  persons  of  suspicious  mien  follow  him  in 
the  streets,  that  they  wish  to  make  way  with  him, 
accuse  him  of  theft,  of  murder,  of  paederasty,  they 
come  to  his  house  to  arrest  him,  to  shoot  him,  etc., 
etc.  It  is  in  this  form  and  when  such  ideas  of  per- 
secution exist  that  we  can  recognize  more  or  less 
perfect  hallucinations  of  hearing  in  the  patient.  A 
tendency  to  suicide  is  almost  the  rule,  and  often 
shows  itself  by  a  sudden  unpremeditated  attempt. 
There  is  here,  as  in  all  attacks  of  alcohcflis/n,  a  very 
marked  tremor  of  the  extremities,  cramps,  formica- 
tions, partial  ansesthesias  or  hypersesthesias,  various 
hallucinations  of  taste  or  smell,  and,  lastly,  more  or 
less  pronounced  gastric  troubles. 

The  maniacal  form  is  nothing  else  than  what  is 


492  TOXIC  INSAJflTlES. 

comrQonlj  known  as  delirium  tremens.  It  begins 
with  insomnia,  incoherence  of  ideas,  and  various 
general  phenomena.  Excitement  soon  appears  and 
rapidly  increases.  The  face  is  red,  swollen  and  con- 
gested, the  eyes  glittering,  the  pulse  frequent,  the 
temperature  elevated,  the  skin  burning  and  covered 
with  sweat,  the  thirst  excessive.  Hallucinations  and 
more  especially  illusions  supervene ;  the  patients  be- 
lieve they  recognize  those  about  them ;  they  take  a 
window  for  a  door,  an  object  for  an  animal,  a  piece 
of  furniture  for  a  person ;  they  find  a  new  taste  and 
odor  to  what  they  eat  or  drink,  and,  lastly,  they 
have  fantastic  visions,  especially  of  animals,  but 
these  are  less  terrifying  than  they  are  in  the  melan- 
cholic form,  and  rather  frequently  they  consist  in 
lewd  representations  and  obscene  tableaux  that  unroll 
themselves  before  the  eyes  of  the  patient.  In  a  very 
short  time  the  agitation  is  at  its  height  and  the  indi- 
vidual cries,  vociferates,  walks  and  runs  without 
cessation. 

The  tremor  is  so  excessive  and  so  generalized  that 
it  has  given  its  name  to  this  variety  of  alcoholic  in- 
sanity. 'J'he  whole  body  is  in  vibration,  as  is  readily 
demonstrated  by  placing  the  hands  on  the  patient's 
shoulders.  The  hands  and  arms  are  agitated  with  an 
extended  uncontrollable  motion,  the  whole  head 
oscillates  visibly,  the  tongue  is  so  tremulous  that 
it  is  drawn  convulsively  out  of  the  mouth;  and, 
finally,  the  tremor  may  sometimes  extend  to  the  lips 
and  vocal  muscles  so  as  to  cause  a  certain  embarrass- 


ALCOHOLIC  INSAlSriTT.  493 

ment  of  speech.  There  may  also  be  an  apparent 
inequality  of  the  pupils,  which  is  rather  common,  as 
we  are  aware,  in  chronic  alcoholism. 

Finally,  we  may  mention  various  more  or  less 
constant  disorders,  such  as  profuse  perspirations, 
accelerated  pulse,  epileptiform  attacks,  and  lastly 
the  usual  disturbances  of  alcoholic  intoxication  in 
the  organic  functions.  As  to  the  temperature,  it  is 
not  sensibly  modified,  and  is  rather  diminished  than 
increased,  especially  in  the  periphery. 

Recovery  is  the  usual  termination  of  the  attack  of 
acute  alcoholic  insanity,  and  it  takes  place  rather 
rapidly  in  from  eight  to  fifteen  days,  from  the  effect 
of  the  simple  suppression  of  the  habitual  stimulation ; 
it  is  evidenced  by  the  return  of  sleep  and  the  pro- 
gressive diminution  of  the  symptoms  of  the  attack. 

C.  Htperactjte  Insanity. — In  the  hyperacute 
alcoholic  insanity  the  attack  attains  a  very  high 
degree  of  intensity.  In  the  melancholic  form  there 
is  an  actual  condition  of  stupor.  Immovable,  stupid, 
incapable  of  answering  or  moving,  with  terrified 
visage,  and  wild  eyes,  the  patients  are  plunged  into 
the  most  profound  prostration;  they  seem  to  be 
taking  part  in  horrible  spectacles,  the  sight  of  which 
terrifies  them,  and  they  onlj^  arouse  themselves  out 
of  this  state  of  prostration  to  make  some  sudden 
attempt  at  suicide.  It  is  in  this  form  in  particular, 
that  they  retain  only  an  extremely  vague  idea  of 
what  has  taken  place  during  their  attack,   and  all 


494  TOXIC  INSANITIES, 

they  have  seeo,  heard,  or  done,  even  their  attempts 
at  suicide,  seems  to  them  like  a  confused  and  remote 
dream.  Nevertheless  these  stuporous  attacks  usually 
disappear  and  end  in  recovery,  but  with  a  certain 
slowness  and  often  leaving  behind  them  various  dis- 
orders, especially  a  state  of  dullness  and  intellectual 
obtusion. 

In  the  maniacal  form  the  agitation  reaches  its 
maximum  and  exhibits  all  the  symptoms  of  acute 
delirium,  from  which,  moreover,  it  derives  its  name 
(alcoholic  acute  delirium) .  Analogous  in  all  respects 
to  simple  acute  delirium,  the  attack  presents,  like  it, 
an  elevation  of  temperature,  which  may  attain  108 
or  109  degrees  or  even  more  (febrile  delirium  tremens), 
typhoid  symptoms,  profuse  perspiration,  fuligin- 
osities,  suhsultus  of  the  tendons,  smallness  of  the 
pulse,  convulsions,  adynamia,  etc.  Like  it  also,  it 
usually  terminates  fatally,  and  this  occurs  either 
suddenly  from  syncope,  or  in  coma. 

The  cerebral  lesions  met  with  most  frequently  in 
acute  attacks  of  alcoholic  insanity,  and  apart  from 
the  habitual  lesions  of  chronic  alcoholism,  such  as 
arterial  atheroma  and  fatty  degeneration  of  the  ves- 
sels, are  hemorrhagic  pachymeningitis,  thickening  of 
the  membranes  and  their  serous  infiltrations,  san- 
guine suffusions,  adhesions  of  the  meninges  to  the 
cortex,  more  or  less  marked  coloration  of  the  gray 
matter,  punctation  of  the  white  substance,  serous 
effusion  in  the  lateral  ventricles,  and  lastly,  hemor- 
rhagic foci  in  various  regions,  especially  in  the  ter- 
ritory of  the  Sylvian  artery  of  the  left  side, 


ALCOHOLIC  INSANITY.  495 

The  diagnosis,  generally  easy,  may  present  some 
difficulty,  in  cases,  for  example,  of  an  acute  attack  of 
the  melancholic  type  and  with  ideas  of  persecution. 
We  have  seen  that  these  cases  are  frequently  mis- 
taken for  incipient  delusions  of  persecution,  and 
vice  versa.  Here,  nevertheless,  the  ideas  of  perse- 
cution are  more  confused  and  more  terrifying,  and 
are  accompanied  with  a  panophohia  that  does  not  ex- 
ist in  partial  insanity. 

As  to  the  alcoholic  stupof  and  alcoholic  acute  de- 
lirium, they  differ  from  the  simple  forms  of  these 
disorders  only  in  their  history  and  the  concomitant 
characters  of  alcoholic  intoxication. 

The  treatment  of  acute  alcoholic  insanity,  is 
blended  with  the  ordinary  treatment  of  alcoholism, 
and,  like  it,  consists  essentially  in  the  suppression  of 
the  customary  stimulants.  It  is  needful,  neverthe- 
less, to  reach  this  suppression  by  easy  stages, 
and  to  gradually  wean  the  patient  from  alco- 
hol by  daily  diminution  of  the  dose.  Insomnia 
being  the  most  constant  result  of  alcoholism,  the 
chief  indication  is  to  re-establish  sleep ;  and  for  this 
reason  sedatives,  and  chloral,  especially  in  full  doses, 
combined  or  not  with  morphine  (Lancereaux) ,  are  the 
therapeutic  agents  that  have  the  best  effect,  partic- 
ularly in  the  excited  forms.  Strychnia  has  also  been 
recently  recommended  for  the  accidents  of  acute 
alcoholism. 

Many    authors,     notably    Lancereaux     {Bulletin 
medical^  1891),  have  tried  to  differentiate  the  alco- 


496  TOXIC  INSANITIES. 

holism  according  to  tlie  nature  of  the  drink  ingested 
(wine,  rum,  cognac,  and  eaux-de-vie,  absinthe, 
vuhieraire,  bitters,  aperatives,  etc.)  The  distinc- 
tion is  less  psychical  than  physical  and  consists  either 
in  the  great  frequency  of  convulsive  accidents 
(absinthism),  or  in  the  different  types  of  disorder  of 
sensibility,  analgesic  in  the  intoxication  from  wine, 
and  hyperalgesic  in  that  from  the  essences. 

M.  Magnan,  and  his  pupil,  Legrain,  have  also  de- 
scribed separately  the  alcoholism  of  hereditary  pre- 
disposed subjects  and  that  of  degenerates. 

3. — AxcoHOLic  Dementia. 

After  chronic  alcoholism  has  continued  a  certain 
time  it,  at  last,  causes  a  progressive  decay  of  the  in- 
dividual, both  in  an  intellectual  and  moral  and  a 
physical  point  of  view.  In  the  physical  sphere  the 
tremor,  the  dyspnoea,  the  alphonia,  the  epileptiform 
convulsions,  the  thickness  of  the  tongue,  the  mus- 
cular weakness,  the  anaesthesia  and  hyperaesthesia, 
the  oculo-pupillary  disorders,  the  fatty  degener- 
ations, loss  of  appetite,  bilious  vomiting,  circulatory 
troubles,  the  congestion  of  the  liver,  etc. ,  etc, ,  are 
the  most  important  of  all  symptoms. 

As  to  the  mental  enfeeblement,  it  begins  slowly  and 
like  all  the  conditions  of  dementia,  first  manifests 
itself  by  the  progressive  failure  of  memory  and  other 
faculties  and  also  by  indifference  and  loss  of  the  sen- 
timents and  the  affections.  The  special  characteris- 
tic of  this  dementia  is  the  almost  invariable  insomnia 


ALCOHOLIC  PSEUDO-GENERAL  PARALYSIS.         497 

that  accompanies  it,  and  the  more  or  less  marked 
hallucinations  that  ma^^  complicate  it  either  continu- 
ously or  in  an  intermittent  fashion. 

By  a  process  of  gradual  degradation  the  patients 
reach  the  untidy  [gdteuoc)  stage  and  end  in  maras- 
mus, being  generally  carried  off  by  an  apoplectic 
attack.  In  some  cases  they  recall  more  and  more 
the  general  aspect  of  paralytic  dementia,  so  that  the 
diagnosis  is  sometimes  rendered  difficult.  The 
tremor,  the  hallucinations,  the  character  of  the 
speech  embarrassment,  and  the  co-existence  of  all 
the  other  signs  of  the  alcoholic  cachexia,  neverthe- 
less permit  generally  the  distinction  of  these  two 
conditions  of  dementia  from  each  other. 

At  the  autopsy  we  find  the  lesions  of  alcoholism 
mentioned  in  the  description  of  the  acute  form  of 
alcoholic  insanity,  to  which  is  sometimes  added  a 
more  or  less  pronounced  atrophy  of  the  cerebrum. 

4. — Alcoholic  General  Paralysis.     Alcoholic  Pseudo- 
General  Paralysis. 

Up  to  within  recent  years  alcoholism  was  consid- 
ered as  one  of  the  most  important  causes  of  general 
paralysis.  Nasse,  in  1870,  called  attention  to  cases 
of  alcoholism  with  all  the  mental  and  bodily  symp- 
toms of  general  paralysis,  but  differing  especially 
in  their  curability  under  the  influence  of  rest  and 
the  deprivation  from  alcoholic  drinks.  Like  Hoff- 
mann, who  had  called  them  2:>seudo-2^a/rafysis,  he  pro- 
posed to  give  these  cases  the  name  of  pseudo-paral- 


498  TOXIC  INSANITIES. 

ysis  e  potii.  The  memoir  and  the  ideas  of  the  Ger- 
man author  were  rather  overlooked,  and  we  contin- 
ued to  make  no  distinction  between  alcoholic  and 
ordinary  general  paralysis,  or  rather  to  continue  to 
admit  the  preponderating  influence  of  alcoholism  in 
the  production  of  this  affection. 

M.  Moreau,  in  1881,  without  accepting  com- 
pletely the  idea  of  Nasse,  sought  to  show  that  alco- 
holic general  paralysis  has  a  peculiar  course,  charac- 
terized by  the  frequency  and  distinctness  of  its 
remissions.  This  difference,  nevertheless,  although 
important,  does  not  seem  sufficient  by  itself  alone  to 
prove  that  there  does  not  really  exist  an  alcoholic 
general  paralysis.  Having  already  studied  the  pre- 
ceding year  the  relations  of  saturnine  encephalopa- 
thy and  progressive  general  paralysis,  and  having 
demonstrated,  contrary  to  the  received  opinion,  that 
lead  poisoning  usually  causes,  not  a  true  genei'al  pa- 
ralysis, but  a  pseudo  form  essentially  curable,  I 
was»  struck,  at  the  time,  v/ith  the  analogy  existing 
between  the  cases  of  so-called  alcoholic  general 
paralysis  and  those  I  had  studied  under  the  name  of 
saturnine  pseudo-general  paralysis.  I  was  therefore 
led  to  accept  fully  the  opinion  of  ISTasse  and  to  ad- 
mit the  existence  of  an  alcoholic  pseudo-general 
paralysis,  in  regard  to  which  I  published  some  con- 
siderations which  were  soon  reproduced  and  devel- 
oped in  the  thesis  of  M.  Lacaille. 

Since  then  a  number  of  cases  have  been  published 
and  many  authors  have  admitted  the  existence  of  an 


ALCOHOLIC  PSEUDO-GENEEAL  PARALYSIS.         499 

alcoholic  pseudo-general  paralysis.  Among  these 
should  be  cited  M.  Ball,  wlio,  by  taking  up  in  one  of 
his  clinical  lectures  the  subject  of  alcoholic  pseudo- 
general  paralysis,  has,  so  to  speak,  officially  declared 
its  existence. 

The  question  of  the  relations  of  general  paralysis 
and  alcoholism  was  agitated  anew  at  a  late  Congress 
of  Alienists  (1891)  by  a  remarkable  report  of  M. 
Rousset.  Various  opinions  were  expressed,  but  it 
seemed  to  be  generally  admitted  that  alcoholic  paral- 
ysis, whether  called  pseudo-general  paralysis  or  not, 
presented  special  features. 

The  pseudo-general  paralyses,  syphilitic,  saturn- 
ine, and  alcoholic,  have  characters  in  common,  and 
the  two  last  especially  present  the  same  clinical 
physiognomy.  They  differ  chiefly  from  general 
paralysis  in  that  they  are  essentially  curable,  or  at 
least  susceptible  of  amelioration  under  appropriate 
treatment. 

In  a  symptomatic  point  of  view  their  analogy 
with  true  general  paralysis  is  nearly  perfect,  and 
they  differ  from  it  only  in  a  few  peculiarities  with- 
out real  importance. 

The  special  characters  of  alcoholic  general  paral- 
ysis, according  to  my  own  observations  and  the 
memoir  of  M.  Lacaille,  are  as  follows : 

Alcoholic  pseudo-general  jDaralysis  always  is  found 
only  in  clearly  established  cases  of  cerebral  alcohol- 
ism, which  is  not  usually  true  of  the  genuine  form. 
It  begins  in  them  in  two  different  ways.     In  some 


500  TOXIC  INSANITIES. 

cases  it  is  announced  and  preceded  by  apoplectiform, 
or  more  particularly,  epileptiform  attacks,  which 
differ  in  certain  respects  from  those  observed  in  the 
beginning  of  general  paralysis.  At  other  times,  and 
this  is  most  frequently  the  case,  the  pseudo-paralysis 
is  consecutive  to  a  subacute  attack  of  alcoholism. 
It  is  in  the  course  of  this  attack  and  on  account  of 
the  insane  acts  caused  by  it,  that  the  patients  are 
sequestrated,  but,  and  this  is  a  remarkable  fact,  they 
do  not,  at  this  time  present  any  of  the  symptoms  of 
paresis,  and  these  latter  only  appear  when  the  sub- 
acute attack  is  over,  or  is  on  the  point  of  disappear- 
ing. In  all  cases,  and  this  is  important  to  note, 
instead  of  being  insensibly  progressive  like  true  gen- 
eral paralysis,  the  symptoms  in  pseudo-paralysis 
attain  at  once  their  greatest  intensity. 

Symptomatically  alcoholic  pseudo-general  paral- 
ysis differs  from  general  paralysis  in  two  ways:  (1) 
it  has  symptoms  peculiar  to  itself ;  (2)  the  symptoms 
common  to  it  and  general  paralysis  present  in  the 
former  some  special  features. 

Its  own  peculiar  symptoms  are  no  other  than  those 
that  belong  to  chronic  alcoholism  and  these  are  too 
well  known  to  require  their  recital  here.  We  may 
add  that  local  paralytic  accidents,  such  as  permanent 
hemiplegia  and  aphasia,  are  more  frequent  and  more 
persistent  than  in  true  general  paralysis. 

The  following  are  the  principal  differences  in  the 
symptoms  they  share  in  common  : 

Contrary  to  what  occurrs  in  true  general  paralysis, 


ALCOHOLIC  PSEUDO-GENEEAL  PARALYSIS.         501 

the  inequality  of  the  pupils  is  scarcely  ever  lacking 
in  alcoholic  pseudo-general  paralysis.  In  it,  more- 
over, the  pupils  are  invariably  very  paretic,  and  in 
some  cases  absolutely  immobile,  especially  the  one 
that  is  most  dilated.  Besides  this  the  pupillary 
aperture  is  very  often  misshapen,  oval,  notched  on  its 
borders ;  the  coloration  of  the  pupil  loses  its  sparkle 
and  transparency ;  it  is  usually  dull  and  cloudy ;  and 
lastly,  the  visual  acuteness  is  ordinarily  diminished. 
These  last  peculiarities  are  exceptional  in  general 
paralysis. 

On  the  part  of  the  intellect,  aside  from  the  delu- 
sional and  hallucinatory  manifestations  that  usually 
mark  the  beginning  of  their  malady,  and  which  may, 
moreover,  reappear  at  any  moment  of  its  progress 
under  the  influence  of  various  causes,  the  pseudo- 
paralytics  are  specially  characterized,  not  by  a  pro- 
gressive enfeeblement  of  the  mind,  such  as  occurs 
in  general  paralysis,  but  by  a  false  dementia,  an  in- 
tellectual obtusion  and  stupidity,  sometimes  carried 
to  the  extreme,  by  an  actual  brutalization. 

That,  however,  which  most  particularly  distinguish- 
es alcoholic  pseudo-general  paralysis  is  its  course. 
While  in  true  general  paralysis,  which  has  for  this 
reason  been  called  progressive^  the  symptoms  gradu- 
ally become  more  and  more  aggravated  and  progress 
almost  invariably  to  the  fatal  termination;  in  the 
pseudo-paralysis,  on  the  other  hand,  their  course  is 
regressive,  that  is  to  say,  that  however  marked  they 
may  have  been  in  the  beginning,   they  gradually 


50^  toxic  INSANITIES. 

diminish  and  may  disappear  entirely  in  a  compara- 
tively short  time.  It  is  a  remarkable  fact,  moreover, 
that  the  disappearance  of  these  symptoms  follows  an 
altogether  different  course  from  that  observed  in  the 
remissions  of  general  paralysis.  While  in  the  latter 
the  pupillary  inequality  is  one  of  the  first  symptoms 
to  be  effaced,  while  the  embarrassment  of  speech 
always  remains  to  a  greater  or  less  degree,  in  the 
pseudo -general  paralysis,  on  the  contrary,  the  in- 
equality of  the  pupils  is  the  most  fixed  and  durable 
of  all  the  symptoms,  while  the  speech  disturbance 
diminishes  from  the  beginning  of  the  amelioration. 

In  a  prognostic  point  of  view  we  may  say  that 
general  paralysis  never,  or  onl}^  very  exceptionally, 
ends  in  recovery,  while  pseudo-general  paralysis 
habitually  does  so.  It  is  also  a  common  thiug  to 
see  alcoholic  pseudo-paralysis  reproduced  repeatedly 
after  new  excesses,  and  each  time  with  recovery, 
until  the  patient  fin  all}''  falls  into  alcoholic  dementia, 
or  is  carried  off  by  an  apoplectic  stroke.  M.  Ball 
and  I  have  reported  the  case  of  a  patient  who  re- 
covered sixteen  times  in  thirteen  years  from  alcoholic 
pseudo-general  paralysis. 

As  regards  the  lesions  of  alcoholic  pseudo-general 
paralysis,  the  one  fact  that  the  disease  may  occur 
and  pass  off  many  times  is  sufiicient  to  prove  a 
priori  that  they  must  be  purely  functional.  I  have, 
in  fact,  published  the  case  of  an  alcoholic  paralytic 
who  died  from  an  accidental  cause,  in  whom  we 
found  at  the  autojjsy  none   of  the  usual  lesions   of 


SATtTENmS  INSAMTY.  503 

general  paralysis.  The  changes  commonly  met 
with  in  the  brain  are  those  already  noticed  of 
chronic  alcoholism,  especially  atheroma  of  the  cere- 
bral arteries  (arterio-sclerosis) ,  and  circumscribed 
lesions  such  as  hemorrhagic  pachymeningitis. 

The  treatment  of  alcoholic  pseudo-general  paral- 
ysis offers  nothing  absolutely  special.  It  consists  in 
aiding  the  tendency  to  recovery  by  the  removal  of 
the  customary  stimulants,  and  appropriate  medica- 
tion, and  especially  the  endeavor,  by  moral  hygienic, 
and  therapeutic  agencies,  to  prevent  the  relapses  so 
frequent  in  these  cases.  It  is  for  this  purpose  in 
particular  and  for  the  patients,  that  the  inebriate 
asylums,  half  hospitals  and  half  homes,  such  as  exist 
in  England,  may  be  of  real  value. 

II.— SATURNISM. 

(Satuenine   Insanity,    Satttrnine   Dementia,    Saturnine    Pseitdo- 
General  Paralysis). 

Saturnism  is  the  result  of  poisoning  by  lead,  as 
alcoholism  is  that  of  poisoning  by  alcohol.  But 
while  the  mental  disorders  due  to  alcoholism  have 
been  the  subjects  of  many  interesting  memoirs,  very 
little  has  been  done  as  regards  satu7"nine  insanity, 
probably  because  it  is  rarer  and  less  frequently  ob- 
served. Apart  indeed  from  the  relations  of  lead 
poisoning  to  general  paralysis,  the  study  of  which 
has  been  begun  by  several  authors,  there  are  still, 
as  regards  the  insanity  caused  by  lead,  only  some 


504  TOXIC  INSAiaTIES, 

vague  references  left  us  by  Tanquerel  des  Planches 
and  Grisolle. 

If  it  is  correct  to  say  that  all  the  toxic  insanities 
present  great  resemblances  to  each  other,  it  is  need- 
ful to  recognize  that  these  analogies  should  not  be 
pushed  too  far  as  regards  the  mental  disturbances 
of  alcoholism  and  lead  poisoning.  Errors  are  often 
committed  in  this  regard.  When  the  saturnine  cases 
come  to  the  asylums,  suffering  from  nightmares,  ter- 
rifying hallucinations,  and  ideas  of  persecution  with 
also  very  marked  tremor  of  the  limbs,  the  physician, 
accustomed  to  look  upon  these  morbid  phenomena 
as  pathognomonic,  does  not  hesitate  to  consider 
them  from  the  beginning  as  suffering  from  the  com- 
bined action  of  alcohol  and  lead.  Thus  the  usual 
form  of  medical  certificate  in  these  cases  is  as 
follows:  "Alcoholic  and  saturnine  insanity."  Here 
is  a  confusion  that  it  is  important  to  notice,  since 
these  patients  have  often  been  guilty  of  no  alcoholic 
excess  and  all  their  symptoms  are  imputable  to  lead 
intoxication. 

This  enables  us  to  dispense  with  any  long  details 
of  the  mental  troubles  of  saturnism,  which  fall  into 
the  same  divisions  and  answer  the  same  description 
as  those  of  alcoholism. 

There  are  therefore :  (1)  a  saturnine  insanity, 
maniacal  or  melancholic,  with  its  subacute,  acute, 
and  hyperacute  varities;  (2)  a  saturnine  dementia; 
and  (3)  a  saturnine  pseudo-general  paralysis. 
Strictly  speaking,  another  still  lighter  form,  may  be 


SATURNINE  INSANITY.  505 

admitted,  lead  inebriety,  more  or  less  analogous  to 
alcoholic  drunkenness. 

1. — Saturnine  Insanity. 

a.  Subacute  Insanity. — Subacute  attacks  of  in- 
sanity in  saturnism,  are  rarer  than  the  acute  variety, 
contrary  to  the  rule  in  alcoholism.  Moreover,  as  in 
the  latter,  the  subacute  attack  almost  always  as- 
sumes the  melancholic  form,  and  is  characterized  by 
the  same  symptoms,  especially  by  insomnia,  terrify- 
ing hallucinations  of  sight,  nightmares,  suicidal 
tendency,  generalized  tremor,  etc.  The  oiAj  differ- 
ence consists  in  the  co-existence  of  the  usual  stig- 
mata of  saturnine  intoxication,  and  notabl}''  the  line 
of  Burton,  which  enable  us  to  make  the  diagnosis. 
Still  this  diagnosis  is  made  more  difficult  when  the 
patient,  as  often  happens,  is  at  once  charged  with 
lead  and  alcohol. 

h.  Acute  Insanity. — Acute  saturnine  insanity  al- 
most always  manifests  itself  under  the  maniacal 
form.  Usually  it  is  announced  by  prodromata,  such 
as  cephalalgia,  depression,  somnolence,  acceleration 
of  the  pulse,  vertigo,  tremor,  and,  in  some  cases, 
albuminuria.  At  other  times  its  onset  is  abrupt. 
Like  the  alcoholic  attack  it  may  come  on  after  a 
rapid  intoxication,  or  from  the  suppression  of  an 
habitual  poison,  sometimes,  finally,  from  the  effect  of 
a  physical  or  moral  traumatism. 

However  this  may  be,  the  first  symptom  is  dis- 
turbance of  sleep,  which  becomes  agitated  and  full 

Ment.  USD.— 33. 


506  TOXIC  INSAlSriTlES. 

of  dreams.  Little  by  little  excitement  appears  and 
increases,  and  delirium  supervenes,  accompanied 
with  illusions  and  more  or  less  terrifying  visual  hal- 
lucinations; a  very  marked  tremor  appears;  the 
patient's  face  is  flushed  and  swollen  and  he  gives  utter- 
ance to  cries,  acts  with  violence,  utters  obscenities; 
in  short,  he  is  an  absolute  picture  of  the  alcoholic 
subject  in  an  acute  attack  of  insanity  from  drink. 

The  duration  of  these  attacks  is  usually  short, 
hardly  extending  beyond  one  or  two  weeks;  recov- 
ery is  the  most  frequent  termination,  and  shows  it- 
self by  the  restoration  of  sleep  and  the  progressive 
disappearance  of  the  symptoms.  Sometimes,  never- 
theless, the  patient  may  die  suddenly  during  the 
attack. 

c.  Hyperacute  Insanity. — Hyperacute  insanity 
is  a  little  more  rare  in  saturnine  intoxication,  and 
when  it  occurs  it  nearly  always  presents  itself  in  the 
melancholic,  that  is,  the  stuporous  form.  As  in  the 
corresponding  form  of  alcoholic  insanity,  the  pa- 
tients are  stupid,  immobile,  in  a  condition  of  fixed- 
ness and  complete  stupor  from  which  they  arouse 
themselves  only  to  make  some  attempt  at  suicide. 
This  form  is  serious,  and  when  it  does  not  cause 
death,  it  always  leaves  behind  it  an  obtusion  of  the 
intelligence  that  may  persist  for  a  long  time. 

The  lesions  found  at  the  autopsy  do  not  generally 
account  for  the  symptoms  observed.  At  most  we 
find  in  some  cases  an  anaemia  of  the  brain  with  more 


SATURNINE  PSEUDO-GENEEAL  PAKALTSIS.        507 

or  less  pronounced  oedema.  It  is  rare  that  we  can 
discover  traces  of  lead  in  the  brain,  especially  in 
acute  intoxication. 

2. — Saturnine  Dementia. 

Just  as  long-continued  alcoholic  intoxication  will 
produce  at  length  a  progressive  physical  and  moral 
decay,  so  slow  poisoning  by  lead  may  give  rise  to 
an  analogous  degradation,  traversed  or  not  as  in 
alcoholism  by  more  or  less  acute  delirious  or  con- 
vulsive episodes.  It  is  to  be  remarked  that  in 
chronic  saturnism  the  dementia  is  precocious  and 
more  profound,  the  cachexia  more  marked,  the  local 
paralysis  and  epileptic  or  eclamptic  convulsions  more 
frequent,  the  marasmus  and  the  untidy  state  more 
rapid,  and  that  after  a  time  of  varying  length  the 
patients  either  succumb  from  the  progress  of  the 
bodily  cachexia  or  are  carried  off  by  a  convulsive 
attack. 

It  is  usual  in  this  form  to  encounter  more  evident 
alterations,  such  as  softening  of  the  brain,  cerebral 
atrophy,  presence  of  lead  in  the  nervous  centres,  etc. 

3. — Saturnine  Pseudo-General  Paralysis. 

Tanquerel  des  Planches  had  already  noted  the 
embarrassment  of  speech  in  the  saturnine  encephal- 
opathy, but  it  was  not  until  1851  that  M.  Delasiauve 
showed  that  certain  forms  of  this  encephalopathy 
might  so  closely  resemble  general  paralysis  as  to 
simulate  that  disorder,  whence  the  name  of  saturn- 


508  TOXIC  INSAIflTIES. 

ine  i:>seudo-general  paralysis  giTen  to  them  by  him. 
IN'evertheless,  a  year  later,  M.  Delasiauve  seemed  to 
modify  his  opinion  and  admitted  the  existence  of  a 
true  saturnine  general  paralysis. 

In  1857  the  work  of  M.  Devouges  appeared,  sanc- 
tioning the  existence  of  a  saturnine  general  paral- 
ysis identical  with  the  ordinary  form. 

Since  that  time  the  question  has  not  been  advanced, 
and,  except  in  a  few  scattered  published  observations, 
the  ideas  of  M.  Devouges  have  been  generally  ac- 
cepted. 

Having  been  struck  by  the  surprising  recoveries  of 
numerous  cases  of  saturnine  general  paralysis  in  my 
own  observation,  I  published  in  1880,  a  paper,  in 
which,  supporting  my  views  on  my  own  experience, 
I  tried  to  show  that  saturnine  general  paralysis  did 
not  r(?ally  merit  the  title,  and  that  it  was  in  reality 
only  a  pseudo-general  paralysis  of  which  I  sketched 
the  principal  features.  From  that  time  the  idea  of 
saturnine  pseudo-paralysis  has  gained  ground  simul- 
taneously vrith  those  of  syphilitic  and  alcoholic  pseudo- 
general  paralysis,  and  some  authors  have  published 
accounts  of  cases. 

Like  alcoholic  pseudo-paresis  the  saturnine  pseudo- 
general  paralysis  most  generally  develops  in  the 
course,  or  rather  as  the  result,  of  a  subacute  attack 
of  saturnine  insanity.  Contrary  to  what  occurs  in 
true  general  paralysis,  its  beginning  is  abrupt,  it 
breaks  out  noisily  and  reaches  its  apogee  at  once. 
As  soon  as  the  hallucinatory  and  deHrious  symptoms 


8ATUENINE  PSEUDO-GENERAL  PARALYSIS.       509 

that  constitute  the  lead  intoxication  have  passed  off, 
the  pseudo-general  paralysis  appears,  not  with  the 
mild  symptoms  of  the  period  of  invasion,  but  with 
the  gravest  characters  of  the  full-fledged  disorder. 
In  most  cases  the  patients  are  plunged  from  the  be- 
ginning into  the  most  profound  cachectic  marasmus. 
They  are  untidy,  paralyzed,  demented,  incapable  of 
making  a  movement  or  uttering  a  syllable ,  and  seem 
to  be  on  the  point  of  succumbing.  At  the  same  time 
they  present  the  usual  symptoms  of  lead  intoxication, 
such  as  the  blue  line  on  the  gums,  clayey  complexion, 
cephalalgia,  dizziness,  cramps,  various  neuralgias, 
partial  anaesthesias  or  hyperajsthesias,  arthropathies, 
paralysis,  epileptic  or  eclamptic  disorders,  etc. 

The  symptoms  common  to  true  general  paralysis 
and  saturnine  pseudo-paralysis,  present  in  this  last 
some  special  shades  of  difference.  Thus  the  pupil- 
lary inequality  is  often  lacking,  the  tremor,  while 
more  intermittent,  is  also  more  marked  and  spas- 
modic, and  the  embarrassment  of  speech  is  occasion- 
ally so  marked  at  the  beginning  that  the  voice  is 
unintelligible.  The  patients,  as  has  been  stated,  are 
often  untidy  and  completely  paralyzed  on  their  first 
admission  to  the  asylum.  Mentally,  besides  the  de- 
lirious and  hallucinatory  manifestations  we  have  de- 
scribed and  which  speedily  disappear,  they  show  a 
type  of  depression  very  different  from  that  of  general 
paralysis.  While,  in  ordinary  paretics  the  enfeeble- 
raent  of  the  intelligence,  at  first  slight,  follows  a  pro, 
gressive  course  and  finally  terminates  in  complete  de- 


510  TOXIC  INSANITIES. 

mentia,  in  the  case  of  saturnine  pseudo-paralytics,  this 
enf  eeblement,  which  appears  at  once  in  its  greatest  in- 
tensity, is  much  more  apparent  than  real.  The  patients 
seem  often  from  the  very  beginning  to  be  suffering 
from  a  complete  abolition  of  the  intellect,  the}^  ap- 
pear absolutely  stupid,  disconnected  in  their  words, 
hardly  able  to  speak  their  own  names.  Neverthe- 
less there  is  no  abolition,  but  merely  a  suspension  of 
their  faculties,  an  obtusion  pushed  to  its  extreme 
limits.  Thus,  after  sometimes  a  very  short  lapse  of 
time,  the  intelligence  reappears,  and  one  is  surprised 
at  being  able  to  witness  the  rapid  awakening  of  the 
patients  who  appeared  to  be  fated  to  an  incurable 
dementia.  As  regards  the  delirium,  gay  or  otherwise, 
of  saturnine  pseudo-general  paralysis,  there  is  little 
of  special  imj^ortance  to  note.  Nevertheless  we 
may  say  that  it  is  less  apparent  than  in  general  paral- 
ysis, as  the  obtunding  of  the  faculties  that  dom- 
inates the  scene  does  not  favor  its  explosion,  but 
that,  on  the  other  hand,  it  is  more  frequently  accom- 
panied by  sensory  disorders.  Lastly,  it  may  be  said 
that,  as  a  rule,  the  saturnine  patient,  at  least  when 
not  in  a  torpid  state,  is  querulous,  coarse  and 
troublesome,  while  the  paralytic  is,  at  least  super- 
licially,  pleasant,  humane,  generous  and  benevolent. 
It  is  especially  as  regards  its  course  and  prog- 
nosis, that  saturnine  pseudo-paralysis  is  distinct  from 
true  general  paralysis.  In  fact,  however  little  differ- 
ent the  symptoms  may  have  been,  they  quickly  im- 
prove and  finally  disappear  as  the  poison  is  eliminated 


MORPHINIC  INSANITY.  511 

from  the  system  by  the  natural  excretions,  which 
fact  makes  this  form  an  essentially  curable  one.  It 
should  be  stated,  however,  that,  like  alcoholic  pseudo- 
paralysis, it  has  a  decided  tendency  to  recur  under  the 
influence  of  the  same  causes. 

It  is  only  in  this  last  event,  and  after  many  suc- 
cessive relapses,  that  the  patients  become  incurable 
and  fall  into  a  condition  of  cachectic  dementia, 
during  which  they  are  generally  carried  off  by  a 
comatose  or  convulsive  attack.  We  find  then  at 
the  autopsy  the  usual  lesions  of  saturnine  dementia, 
and  sometimes  also  some  non- cortical  meningeal 
lesions. 

The  treatment  consists  chiefly  in  favoring  the 
elimination  of  the  poison.  It  is  necessary  therefore 
to  use  sulphur  baths,  and  iodide  of  potash  combined 
with  the  bromides.  It  is  necessary,  in  order  to  pre- 
vent a  return  of  the  symptoms,  to  formally  pledge 
the  patient  to  change  his  occupation. 

III.— MORPHINISM. 

(MoRPHiNic  Insanity). 

Morphinism  is  the  sum  of  the  accidents  due  to 
poisoning  by  morphine.  It  may  be  medical,  that  is, 
the  result  of  a  more  or  less  prolonged  medication 
with  morphine,  but  almost  always  it  succeeds  mor- 
phinomania,  that  is,  the  passion  of  the  patient  for 
morphine. 

There  is  no  need  here  of  giving  the  history  of 


512  TOXIC  INSANITIES. 

morphinisin  or  of  morphinomania  or  of  explaining 
how  subcutaneous  injections  of  morpliine,  recom- 
mended by  a  physician  to  calm  the  sufferings  of  his 
patients,  have  become  in  a  short  time  the  fashionable 
poison  in  certain  classes  of  society,  among  whom 
they  are  already  making  the  greatest  havoc.  What 
is  of  interest  for  us  to  know  is  that,  like  all  other 
toxic  agents,  morphine  is  capable  of  provoking 
mental  disorders  of  various  kinds,  and  the  history  of 
certain  recent  criminal  trials  shows  that  the  medico- 
legal chapter  of  morphinism  has  been  opened. 

A  number  of  works  have  already  appeared  on 
morphinism  and  morphinomania,  but  the  course  of 
lectures  of  M.  Ball  on  this  subject  was  one  of  the 
earliest  studies  that  particularly  discussed  the  psychic 
disorders  of  this  intoxication.  Since  its  appearance 
the  question  has  been  treated  fully  and  at  length  in 
many  works  (Jennings,  Pichon,  Guimbail,  etc.) 

In  a  general  way  the  insanity  caused  by  morphin- 
omania resembles  in  all  points  all  the  other  toxic  in- 
sanities, and  like  them  manifests  itself  in  more  or 
less  acute  attacks  of  mania  or  melancholia,  with 
insomnia,  terrifying  visual  hallucinations,  tremors, 
etc.  Morphinomania,  however,  causes  insanity  more 
rarely  than  the  other  intoxications,  and  usually  gives 
rise  to  intellectual  disorders  that  confine  themselves 
to  the  domain  of  semi-alienation. 

It  is  useful,  therefore,  to  make  a  distinction  between 
the  accidents  due  to  the  abuse  of  morphine  and  those 
caused  by  its  suppression,  as  both  may  be  the  origin 


MOEPHINIC  INSANITY.  513 

of  mental  disorder,  which,  as  we  have  seen,  was  also 
the  case  with  alcohol  and  lead. 

1.  Effects  of  Abuse. — The  first  effects  of  the  ab- 
sorption of  the  poison  are  generally  agreeable,  and 
this  period  of  stimulation  may  last,  according  to  the 
cases,  from  a  few  weeks  to  some  years.  Dating 
from  the  moment  that  the  passion  becomes  tyran- 
nical, or  the  morphine  habitue  becomes  a  morphino- 
maniac,  the  disorders  appear  more  or  less  rapidly, 
and  the  following  intellectual  and  moral  symptoms 
may  present  themselves : 

The  first  effect,  as  has  been  said,  is  a  feeling  of 
well-being  and  happiness — a  sort  of  stimulation  of 
the  faculties.  Soon,  however,  the  will  becomes  paral- 
yzed and  the  patient  has  not  enough  energy  to  rouse 
himself  from  his  torpor  and  renounce  his  habit. 
Often  indeed  he  lacks  the  force  to  leave  his  couch 
(manie  lectuaire) .  Memory  and  judgment  do  not 
seem  seriously  affected,  but  they  may  show  a  certain 
degree  of  obtusion.  The  moral  sense  is  nearly  always 
profoundly  blunted;  the  morphinomaniacs  commit 
indelicate  acts,  sometimes  also  misdemeanors  or  actual 
crimes.  Finally,  their  instincts  may  be  depraved,  and 
they  frequently  indulge  in  all  sorts  of  excesses,  even 
to  debauchery  that  is  actually  pathological.  Sleep 
is  always  disordered  and  sometimes  almost  abolished ; 
at  the  most  there  is  then  produced  a  tendency  to 
diurnal  somnolence,  but  not  supplying  the  needed 
rest.  When  all  these  disturbances  attain  a  certain 
degree   of  intensity,  there   are  usually  added  some 


514  TOXIC  INSANITIES. 

more  serious  symptoms  such  as  panic  terrors,  hallu- 
cinations, mainly  yisual,  but  possibly  also  of  taste 
and  smell.  Occasionally  there  is  a  true  melancholic 
state,  with  prostration,  delusions  of  persecution, 
suicidal  tendency,  etc.  Acute  mania  is  less  common, 
though  it  may  be  observed ;  thus  in  the  opium  resorts 
of  Indo-China,  we  may  see  Malays,  in  a  paroxysm 
of  fury  from  having  lost  at  play,  rush  into  the  street, 
knife  in  hand. 

Finally,  the  prolonged  abuse  of  morphine  may  at 
last  cause  a  state  of  dementia,  more  or  less  anal- 
ogous to  the  other  toxic  dementias. 

With  these  purely  psychic  disorders  occur  the 
array  of  physical  symptoms  of  the  poisoning,  such 
as  anesthesia  or  hypersesthesia,  diminution  of  the 
reflexes,  increased  appetite,  obstinate  constipation 
with  tenesmus,  dysuria,  hoarseness  of  the  voice,  in- 
duration of  the  skin,  tendenc}^  to  local  accidents  at 
points  of  puncture,  and  lastly  the  aged  and  wrinkled 
appearance  of  the  face. 

2.  Effects  of  Abstinence. — These  effects  are  pro- 
duced in  morphinomaniacs  who,  either  voluntarily  or 
involuntarily,  find  themselves  suddenly  deprived  of 
tlieir  habitual  stimulants.  Among  the  effects  of 
abstinence  there  are  some  identical  with,  and  others 
opposed  to,  those  that  result  from  abuse.  Mentally 
we  see  the  euphoria  disappear  and  be  replaced  by 
irritability,  inequalities  of  character  and  humor,  and 
tendency  to  criticise  and  see  evil  in  everything.  To 
this  is  joined  a  greater  or  less  degree  of  sentiment- 


lilOEPHINIC  INSANITY. 


515 


ality,  incapacity  for  work,  mental  weakness,  somno- 
lence, and  weakness  of  the  will.  In  some  instances 
the  patients  are  inert  and  torpid,  they  will  not  leave 
their  beds ;  in  other  cases,  on  the  contrary,  they  are 
excessively  agitated,  go  and  come,  unable  to  remain 
in  any  one  place,  they  weep  and  groan  and  lament  on 
all  occasions.  Sometimes  they  also  have  hallucina- 
tions of  sight,  smell,  and  taste.  Insomnia  is  gen- 
erally complete.  In  some  cases  a  genuine  attack 
of  insanity  declares  itself,  commonly  maniacal  in 
form,  and  occasionally  even  a  true  trembling 
delirium. 

The  concomitant  physical  disorders  in  the  sensory 
and  motor  and  organic  functions  are  much  more  pro- 
nounced than  in  case  of  the  abuse  of  morphine,  and 
ma}^  terminate  in  a  very  serious  condition,  such  as 
collapse,  capable  of  causing  death.  The  best  treat- 
ment in  these  cases  is  the  return  to  the  morphine  in- 
jections, which  often  causes  the  symptoms,  serious 
as  they  seem,  to  disappear  as  if  by  magic. 

The  diagnosis  of  morphinic  mental  alienation, 
consists  essentially  in  detecting  the  morphinomania, 
often  sedulously  concealed  by  the  patients.  Besides 
the  usual  s^^mptoms  of  morphinism,  the  appearance 
of  the  skin  with  traces  of  punctures,  and  the  exam- 
ination of  the  urine,  which  contains  the  alkaloid 
even  after  many  days'  abstinence,  w^ill  suffice  to  re- 
lieve all  doubts. 

The  prognosis  is  grave,  as  there  is  no  passion 
more  tyrannical   than  that  for  morphine,  and  if  we 


516  TOXIC  INSAI5-ITIES. 

cannot  Yanquish  it  or  at  least  attenuate  it  by  a  pro- 
gressive diminution  of  tlie  dose,  the  patients  gener- 
ally succumb  finally  to  marasmus  or  phthisis. 

The  treatment  consists  either  in  the  gradual  or 
the  abrupt  discontiu nance  of  the  drug,  the  latter  be- 
ing the  more  dangerous  and  capable  of  producing 
the  serious  effects  of  abstinence.  A  third  method, 
intermediate  between  these  two,  that  of  Erlenmeyer, 
consists  in  the  sudden  suppression  of  the  ration  de 
luxe,  and  the  gradual  diminution  of  the  dose  until 
complete  suppression  is  attained.  Isolation  in  an 
asylum  is  often  necessary,  and  some  authors  do  not 
hesitate  to  make  this  the  basis  of  the  treatment.  It 
is,  in  fact,  almost  the  only  means — and  yet  some- 
times insufficient — of  preventing  the  morphinoma- 
niac  from  deceiving,  and  obtaining  by  easily  plotted 
ruses,  his  customary  excitant.  In  order  to  avoid 
their  seclusion  in  insane  asylums,  there  have  been 
some  special  establishments  founded  abroad  [Heil- 
anstalten  fur  MorphiumsUditige)  for  these  cases, 
where  the  plan  consists,  as  at  Gratz,  in  the  ab- 
rupt and  complete  discontinuance  of  the  poison, 
without  other  treatment  than  immediate  interven- 
tion, but  without  morphine,  in  case  any  compromis- 
ing accidents  supervene. 

In  the  early  stages  of  treatment  by  gradual  dimi- 
nution of  the  dose,  other  treatment  may  be  limited 
to  the  administration  of  some  sedatives,  such  as 
bromide  of  sodium,  chloral,  and  picrotoxine.  In  the 
second  period,  if  phenomena  of  cardiac  and  general 


MOEPHINIC  INSANITY.  517 

depression  show  themselves,  it  is  necessary  to  stim- 
ulate the  organism.  We  may  proceed  in  this  hy 
substitution,  replacing  the  morphine  by  some  other 
agent,  such  as  opium,  alcohol  in  full  (Joses,  cocaine 
(a  very  dangerous  agent),  atropine,  haschisch,  nux 
vomica,  caffeine,  and  lastly,  phosphate  of  codeine, 
in  the  dose  of  ten  to  fifty  centigrammes  by  hypoder- 
mic injections,  that  was  specially  recommended  as  a 
basis  of  treatment  by  M.  Guimbail.  As  a  stimu- 
lant, strophanthine  may  be  utilized  (half  a  milli- 
gramme hypodermically) ,  sulphate  of  spartein,  nitro- 
glycerine or  trinitrine  (Jennings),  fluid  extract  of 
kola,  etc. 

When  the  hypodermics  are  discontinued,  that  is, 
in  the  third  stage  of  the  treatment,  one  must  combat 
the  accidents  that  may  occur.  For  the  vomiting,  iced 
or  very  warm  drinks,  quiet  horizontal  position,  alco- 
holized black  coffee,  extract  of  belladonna.  For  the 
diarrhoea,  naphthol,  salol  or  salicylate  of  bismuth  in 
full  doses,  extract  of  opium.  For  the  accidents 
of  collapse,  energetic  cutaneous  revulsives,  douches, 
cold  affusions,  warm  batlis,  sinapisms,  urtication, 
faradization  of  the  skin  and  especially  of  tlie  phrenic 
nerves,  injections  of  ether,  and,  finally,  in  very  se- 
vere cases,  the  injection  of  morphine,  which,  nine 
times  out  of  ten,  is  sufiicient  to  arouse  the  organism 
from  near  the  point  of  extinction,  or  again,  as  a  last 
resort,  transfusion  of  blood. 

The  adjuvants  to  this  treatment  are  numerous,  and 
vary  according  to  the  case :  hydrotherapy,   Turkish 


518  TOXIC  nfSAiaTiEs. 

baths,  massage,  static  electricity,  heat,  yalerian, 
bromides,  chloral,  alkalines,  milk,  mechanical  stimu- 
lations, and  exercise  and  amusements  when  prac- 
ticable. 

Hypnotism,  highly  praised  by  some  physicians, 
may  give  good  results,  but  onlj  in  certain  special 
cases.  The  same  is  true  of  all  the  agencies  that  act 
by  strongly  impressing  the  feelings  and  imagination 
of  the  patients,  such  as  violent  emotions,  religious 
ceremonies,  pilgrimages,  etc. 

IV.— OTHER  mTOXICATIONS. 

(ABSrN'THISM,  EtHEKISM.  ChLOKAUSM.  COCArNISM,   OXYCAKBOjnSM,  ETC.) 

Alcohol,  lead,  and  morphine  are  not  the  only 
substances  capable  of  causing  cerebral  disorders. 
There  are  very  many  others  that  have  more  or  less 
analogous  effects  on  the  organism.  The  description 
of  all  the  toxic  deliriums,  useless  here,  finds  its  proper 
place  in  a  special  study  of  the  subject,  such,  for 
example,  as  that  of  M.  Pichon  (Xes  maladies  de 
V esprit^  1888),  or  that  of  M.  Legrain  {Les  poisons 
de  V intelligence^  1891).  We  will  content  ourselves 
with  recapitulating  very  briefly,  at  the  end  of  this 
chapter,  the  principal  characters  of  certain  intoxi- 
cations to  which  attention  has  been  more  specially 
directed  of  late  years. 

Ahsinthism. — Absinth  ism  differs,  by  some  peculi- 
arities, from  alcoholism.  Instead  of  the  anajsthesia 
of  the  analgesic  type  observed  in  the  former,  there 


ETHEEISM,  CHLORALISM.  519 

is  hypersesthesia  of  the  feet  (Lancereaux)  and  very 
marked  exaggeration  of  the  patellar  and  plantar  re- 
flexes. Moreover  the  accidents  have  in  this  intoxi- 
cation a  much  more  rapid  evolution  to  dementia. 

The  conscious,  irresistible  impulsions  are  much 
more  violent  than  in  alcoholism.  In  chronic  absinth- 
ism,  or  in  the  intervals  between  the  attacks,  it  is 
not  uncommon  to  see  a  sort  of  conscious  melancholic 
state  (Gilson).  Finally,  the  epileptiform  attacks, 
which  are  very  frequent,  resemble  the  comitial 
attacks. 

Ether  ism. — This  intoxication  is  comparable  to 
that  from  morphine,  but  is  rarer  and  less  grave. 
The  passion  for  ether,  ether oynania^  is  not  accom- 
panied with  the  same  degree  of  irresistible  craving  for 
the  stimulant.  The  deprivation,  also,  of  the  drug 
produces  quite  a  different  condition  from  the  state 
of  distress  of  the  morphinomaniac,  and  is  not  accom- 
panied with  the  same  serious  accidents. 

Chloroformism.,  which  is  very  uncommon,  also 
presents  analogous  characters.  Dr.  Savage  has  cited 
cases  wherie  surgical  ana3sthesia  with  chloroform, 
ether,  or  protoxide  of  nitrogen,  has  been  sufficient  to 
provoke  in  persons  who  had  been  formerly  insane  or 
those  predisposed  to  insanity,  either  a  temporary 
toxic  delirium  or  the  return  of  a  vesanic  alienation. 

Chloralisyn. — Chloralism  is  characterized,  like 
morphinism,  by  an  irresistible  tendency  to  the  ab- 
sorption  of   progressively  increasing  doses  of   the 


520  TOXIC  INSANITIES. 

drug,  and  by  a  genuine  state  of  distress  that  is  pro- 
voked by  the  abstinence  after  its  long  continued 
employment,  but  with  less  serious  symptoms.  The 
bodily  symptoms  seem  to  consist  mainly  in  gastro- 
intestinal disturbances.  Psycho-sen sorial  accidents 
are  rare,  but  there  is  usually  some  mental 
enfeeblement. 

Haschischism^  llieism^  Vanillism^  and  Nico- 
tinism cause  analogous  effects  on  the  system  to  those 
passed  in  review. 

Cocaiyiism. — Erlenmeyer,  Magnan  and  Saury, 
Pichon,  Segias,  Chalmers  da  Costa,  Hallopeau, 
Chouppe,  and  some  other  authors,  have  called  atten- 
tion of  late  years  to  the  cerebral  disorders  engen- 
dered by  cocaine.  In  most  of  the  cases  observed, 
the  intoxication  was  from  morphine  and  cocaine 
simultaneously,  thus  complicating  the  distinction  of 
the  symptoms.  The  special  effects  of  cocaine  have, 
nevertheless,  been  observed  in  patients  free  from 
morphinism  or  alcoholism.  According  to  Magnan 
and  Saury,  the  leading  symptom  is  found  in  the  ex- 
istence of  special  cutaneous  impressions  (sensations 
of  worms,  insects,  microbes,  vermin  around  the  body, 
in  the  skin  or  in  the  wounds  of  the  punctures) ;  next 
come  hallucinations  of  sight,  hearing,  or  smell,  and, 
finally,  delirium  composed  of  hypochondriacal  ideas 
and  those  of  persecution.  There  are  also  sometimes 
ocular  disturbances  (diplopia,  amblyopia,  dyschro- 
matopsiaj  and,  even  after  small  doses  as  in  Chalmers 


OXY-CAEBONISM,  ETC.  521 

da  Costa's  case,  tetaniform  condition,  collapse,  hys- 
tero-epileptiforra  convulsions  and  violent  agitation. 

Cocaine  may  be  considered  as  the  agent  of  a  grave 
intoxication  and  as  causing  in  tlie  system  rapid  and 
serious  ravages.  It  is  a  drug  that  should  be  entirely 
abstained  from,  at  least  in  the  form  of  hypodermic 
injections. 

Oxy-carhonism. — The  vapor  of  oxide  of  carbon 
may  give  rise  to  an  intoxication,  either  chronic  and 
professional,  as  in  ironers,  or  accidental  and  acute  as 
in  poisoning  by  movable  stoves.  This  intoxication 
has  been  specially  studied  of  late  years  by  Woelcken, 
Lancereaux,  Briand,  Moreau  (de  Tours),  etc.,  etc. 

The  dominant  psychic  symptom  and  the  one  that 
constitutes  the  characteristic  phenomenon  in  acute 
cases,  is  amnesia,  usually  retrograde  and  going  back 
more  or  less  beyond  the  poisoning.  We  also  observe, 
especially  in  the  slow  intoxication,  other  phenomena, 
such  as  vertigo,  oppression,  syncope,  mental  obtu- 
sion, hallucinations  of  sight  and  hearing,  delusive 
conceptions  (notions  of  persecution). 

If  these  symptoms  are  not  of  too  long  standing 
the  removal  of  the  action  of  the  deleterious  gas 
causes  them  all  to  disappear.  If  the  case  is  other- 
wise, rapid  and  incurable  dementia  ensues. 

The  treatment  should  consist  mainly  in  hygienic 
measures,  tonics  and  reconstituents.  In  the  acute 
stage  alkaline  bromides,  bromohydrate  of  quinine, 
prolonged  warm  baths,  and  vertebral  affusions. 

MfiNT,  Med.— 33. 


SECOKD   PART. 


APPLICATIONS    OF 

MEXTAL    PATHOLOGY 

TO    PRACTICE. 


FIRST    SECTION. 

MEDICAL   PRACTICE. 
DIVISION. 

The  practical  part  of  mental  alienation  divides 
naturally  into  two  sections:  (1)  medical  practice, 
wliicli  relates  to  the  treatment  of  the  insane,  and  the 
various  matters  appertaining  to  it;  (2)  medico-legal 
practice,  which  includes  the  medical  study  of  the 
forensic  questions  in  regard  to  the  insane. 

The  medical  practice  is,  unquestionably,  the  one 
that  chiefly  interests  the  physician,  as  it  treats  es- 
pecially of  the  relations  of  every  kind  that  he  may 
have  with  the  insane,  either  during  the  course  of 
their  disease,  while  they  are  at  liberty,  or  up  to  the 
moment  of  their  entry  into  the  asylums  when  they 
are  destined  to  sequestration.  But  the  various 
points  that  make  up  this  practice  have  never  been 


DIVISION,  523 

formulated  in  any  precise  manner,  and  there  does 
not  exist,  properly  speaking,  any  professional  code 
destined  to  guide  the  physician  in  the  current  prac- 
tice as  regards  mental  alienation.  Without  in  any 
way  pretending  to  fill  up  this  lacuna,  I  have  thought 
that  in  a  Manual  intended  especially  to  be  practical, 
and  which  addresses  itself  more  particularly  to  phy- 
sicians who  are  not  specialists,  these  practical  pro- 
fessional questions  ought  necessarily  to  occupy  an 
important  place.  I  have  therefore  attempted  to 
formulate  some  general  precepts  relative  to  the  prin- 
cipal situations  in  which  the  physician  may  find 
himself  in  his  practice  in  relation  to  the  insane. 

These  situations  seem  to  me  to  be  summed  up  in 
a  general  way  in  the  following  indications : 

1.  The  physician  is  called  to  see  a  patient 
supposed  to  be  insane.  His  task  is  to  find  out 
whether  the  individual  is  really  insane  or  not  and 
what  is  the  form  of  the  malady.  This  is  what 
may  be  called  the  practical  diagnosis  of  mental 
alienation. 

2.  The  existence  of  mental  alienation  and  its 
form  being  determined,  it  remains  to  say  what 
measures  are  to  be  taken  in  regard  to  the  case,  the 
necessity  or  otherwise  of  internement.  This  second 
point  therefore  consists  essentially  in  the  medical 
judgment  as  to  the  need  of  sequestration. 

3.  These  points  settled,  the  duty  of  the  phy- 
sician varies  according  to  whether  or  not  confine- 
ment   is    ordered.      In    case   it    is    directed,    the 


524  MEDICAL  PRACTICE. 

physician  should  proceed  to  make  use  of  the 
formalities  prescribed  by  the  law  in  such  cases, 
and  from  that  moment  the  patient  is  submitted  to 
the  authority  of  those  who  liave  tlie  care  and  treat- 
ment of  the  inmates  of  special  establishments  for  the 
insane.  There  are  here  therefore  two  distinct  things : 
(1)  the  commitment  of  tlie  insane ;  (2)  the  situation 
and  treatment  of  the  insane  in  confinement. 

4.  If  confinement  is  not  found  to  be  necessary  or 
is  for  any  reason  impracticable,  the  patient  is  left 
at  liberty  and  the  physician  adopts  an  appropriate 
treatment  suited  to  the  case.  This  is  the  treatment 
of  the  insane. 

5.  Finally,  the  physician  may  be  called  on  to  act 
in  certain  conditions,  either  in  regard  to  the  insane 
themselves,  or  for  their  friends:  for  example,  to  lay 
down  rules  for  a  prophylactic  treatment  for  the 
patients  or  their  children,  and  especially  to  give 
opinions  on  the  matter  of  heredity,  as  regards  the 
future  of  their  children,  or  in  regard  to  a  proposed 
marriage  b}^  a  member  of  their  family.  This  is 
what  may  be  called  medico-mental  deontology. 

We  shall  now  study  briefly,  in  difl'erent  chapters, 
these  various  points  of  medical  practice  in  mental 
alienation,  viz.  : 

1.  The  practical  diagnosis  of  mental  alienation. 

2.  Medical  estimation  of  the  necessity  of  seques- 
tration. 

3.  Placing  the  insane  in  special  establishments. 

4.  The  treatment  of  the  insane. 

5.  Medico-mental  deontology. 


Cbapter  IF* 

THE   PRACTICAL  DIAGNOSIS  OF  MENTAL 
ALIENATION. 

Just  as  diagnosis  in  ordinary  medicine  is  com- 
posed of  two  distinct  elements:  the  study  of  the 
history  of  the  case  and  the  examination  of  the 
patient,  so  also  and  even  more  so  in  mental  medicine 
it  is  absolutely  indispensable  that  we  should  inform 
ourselves  as  to  the  antecedents  of  the  case  before 
proceeding  to  the  interrogation  and  direct  exam- 
ination of  the  patient. 

But  while  in  ordinary  medical  clinics  the  patient 
can  usually  give  the  facts  needed  by  the  physician 
for  his  diagnosis,  even  better  than  anyone  else,  in 
the  mental  clinic  it  is  almost  always  impossible  to 
proceed  in  this  way,  and  it  becomes  necessary  to  get 
the  history  from  another  source.  The  majority  of 
the  insane,  indeed,  cannot  furnish  the  slightest 
serious  indication  as  to  their  past,  some,  like  the  de- 
generates and  the  dements,  because  they  are  incapa- 
ble; others,  like  the  excited  and  incoherent  cases, 
because  it  is  impossible  to  fix  their  attention ;  some, 
like  the  melancholiacs,  from  their  more  or  less  abso- 
lute mutism;  and  others,  finally,  like  the  victims  of 
persecutory  delusions,  on  account  of  their  reticence 
and  because  they  think  they  see  a  trap  in  the  queS' 
tions  asked  them. 


526  PEACTICAL  DIAGNOSIS  OF  INSANITY. 

It  is,  therefore,  usually  inexpedient  to  begin 
directly  witli  the  patient  without  previously  ac- 
quired information,  and  before  obtaining  this  it  is 
needful  to  interrogate  the  members  of  his  family  or 
some  one  very  closely  associated  with  him.  By 
thus  doing  we  can  obtain  valuable  information  that 
will  give  important  aid  in  examination  and 
diagnosis. 

History. — The  facts  to  be  obtained  from  the  rela- 
tives or  intimate  associates  include :  (1)  the  family 
history;  (2)  the  personal  antecedents  of  the  patient. 
As  these  very  often  include  matters  of  extreme  deli- 
cacy, the  physician  should  in  questioning,  show  him- 
self to  be  discreet,  reserved,  should  use  the  greatest 
circumspection  and  make  the  persons  he  interrogates 
understand  that  all  these  details,  far  from  being 
superfluous,  may  have,  on  the  contrary,  a  very  great 
importance.  And  after  all  we  must  not  forget  that 
the  information  thus  obtained  is  far  from  being  the 
exact  expression  of  the  truth.  Either  from  honest 
ignorance  or  more  often  still  from  a  feeling  of  repug- 
nance or  false  shame  very  common  in  society,  the 
members  of  the  patient's  family  very  frequently  fail 
to  give  the  physician  the  truth  as  regards  hereditary 
antecedents.  We  may  also,  in  a  general  way,  ac- 
cept as  under  the  reality  the  semi-admissions  we 
obtain  in  this  regard. 

1.  Family  History. — In  investigating  the  family 
history  oae  must  not  limit  himself  to  obtaining  data 


HISTORY.  527 

as  to  the  patient's  father  and  mother,  that  is  to  say, 
to  his  direct  ancestors.  It  is  equally  necessary  to 
learn  in  regard  to  his  collateral  heredity  and  his  de- 
scendants, and  particularly  to  go  back  in  the  direct 
heredity  to  the  grand-parents.  We  have  seen,  in- 
deed, that  heredity  in  certain  families  sometimes 
jumps  one  generation  to  appear  again  in  the  suc- 
ceeding one,  so  that  the  insanity  of  an  individual, 
leaving  his  immediate  descendants  intact  or  at  least 
existing  in  them  only  in  a  latent  condition,  may 
break  out  in  his  grandchildren.  It  is  well  therefore 
to  obtain  information  whether  there  have  not  ex- 
isted in  the  paternal  or  maternal  ancestors,  or  in  the 
collaterals  or  descendants,  well  defined  cases  of  men- 
tal disorder,  spinal  disease,  neuroses,  alcoholism, 
suicide,  abnormal  vices  or  criminality,  deaf -mutism, 
consanguineous  marriages,  diatheses  in  general  (tu- 
berculosis, arthritism,  cancer,  syphilis),  or  simply 
cases  of  eccentricity,  or  defective  psychic  organiza- 
tion; since,  as  Morel  has  justly  remarked,  insanity 
is  very  frequently  not  the  direct  result  of  in- 
sanity, but  is  rather  that  of  a  predisposition 
that  is  shown  in  the  ancestors  only  by  some 
simple  oddity  of  character,  or  by  an  isolated 
tendency  to  sadness  or  excitement.  In  addition  to 
these  facts  there  are  some  others  the  knowledge  of 
which  may  be  of  interest.  Thus  it  is  well  to  know, 
when  we  can,  if  the  patient  is  not  illegitimate,  if  at 
the  time  of  his  presumed  conception  his  parents 
were  young  or  old,  if  they  were  under  the  influence 


528  PEACTICAIi  DIAGNOSIS  OF  IKSANTTY. 

of  alcoliolic  excitement,  were  recovering  from  any 
long  or  serious  illness,  or  suffering  from  any  kind  of 
exhaustion,  etc.,  etc.  It  is,  in  fact,  very  important 
to  specify  the  nature  of  the  diseases  or  the  morbid 
peculiarities  that  may  have  existed  in  the  family, 
since  all  kinds  of  alienation  do  not  have  the  same 
origin  or  recognize  the  same  heredity.  Thus  at  the 
present  time  the  tendency  is  to  admit  tliat  general 
paralytics  do  not  usually  descend  from  insane  parents 
but  from  subjects  of  tendency  to  other  cerebral  dis- 
orders, while  the  heredity  of  the  insane  properly  so- 
called,  is  from  vesanic  ancestors.  We  know  also 
that  certain  varieties  of  insanity  such  as  double  form 
insanity,  and  hereditary  suicide,  are  inherited  from 
ancestors  similarly  affected,  while  in  the  other  types 
the  heredity  is  dissimilar  as  a  rule.  It  will  be  un- 
derstood that  these  indications,  drawn  from  heredity 
and  its  form,  may  be  of  importance  in  cases  where 
the  diagnosis  presents  difficulties,  for  example,  when 
we  are  endeavoring  to  establish  or  reject  the  exist- 
ence of  general  paralysis.  In  such  case  the  assured 
proof  of  vesanias  in  the  progenitors  would  be  a  fact 
against  the  presumption  of  general  paralysis,  which 
on  the  other  hand  would  be  supported  by  a  history 
of  apoplexy  or  hemiplegia  of  the  parents. 

The  important  question  of  heredity  settled,  not 
only  as  to  its  existence,  properly  speaking,  but  also 
as  to  all  its  characters  of  multiplicity,  complexity, 
form,  etc.,  it  is  of  importance  to  study  the  family  of 
the  patient,  as  to  its  general  constitution,  the  prin- 


HISTORY. 


529 


cipal  manifestations  of  its  life,  in  that  whicli  we 
have  studied,  with  M.  Ball,  under  the  name  of  the 
biological  characters  of  the  family.  The  principal 
of  these  characters  are :  the  longevity,  or  duration 
of  life,  usually  rather  long  in  the  families  of  the 
insane;  the  natality,  or  average  number  of  births, 
also  high  in  families  of  the  mentally  alienated,  es- 
pecially in  those  subject  to  cerebral  accidents ;  the 
vitality  or  vital  power,  less  in  early  life  on  the  con- 
trary in  these  families.  We  may  find  here  certain 
indications,  certain  peculiarities  that  betray  the 
hereditary  taint,  and  show  clearly  the  degeneracy 
and  the  form  of  degeneracy  that  weighs  upon  the 
race. 

2,  Antecedents  of  the  Patient. — The  family  of 
the  patient  known,  both  as  to  the  ascendants  and  the 
descendants,  it  is  needful  to  become  informed  as  to 
himself,  and  this  from  the  period  of  his  birth  up  to 
the  time  we  are  called  to  examine  him.  This  in- 
quiry therefore  includes  two  distinct  parts :  A. — the 
history  of  the  life  of  the  patient  up  to  the  disorder; 
B. — the  history  of  his  disease. 

A. — In  regard  to  this  first  point  we  should  inquire 
rapidly  as  to  all  the  main  points  of  the  patient's  life, 
his  age,  civil  condition,  physical,  mental  and  moral 
constitution,  his  resemblance  in  these  respects  to  this 
or  that  of  his  progenitors,  his  degree  of  mental  cul- 
ture, his  character,  tastes,  religious  sentiments,  in- 
stincts, habits  and  penchants ;  should  inquire  if  he 


530  PRACTICAL  DIAGNOSIS  OF  INSANITY, 

is  nervous  and  impressionable ;  at  what  epoch  puberty 
appeared  and  how ;  if  the  patient  is  a  female,  inquire 
as  to  the  catamenia,  whether  suppressed,  difficult, 
or  normal,  whether  or  not  their  return  is  accompanied 
with  psychic  or  nervous  disturbances,  whether  there 
have  been  any  pregnancies  and  how  many,  how  they 
have  been  endured;  one  should  learn  whether  the 
patients  have  not  been  or  are  not  still  affected  with  any 
serious  disorder  (meningitis,  convulsions,  typhoid 
fever,  visceral  disease,  or  any  diathesis  whatever, 
especially  former  attacks  of  insanity) ;  if  they  have 
not  received  injuries,  particularly  blows  on  the  head ; 
if  they  have  been  guilty  of  alcoholic  or  sexual  ex- 
cesses ;  if  they  have  not  used  tobacco  excessively,  or 
morphine  or  any  other  poison ;  if  their  occupation  has 
exposed  them  to  any  intoxication  or  other  deleterious 
influences ;  if  they  have  had  domestic  difficulties,  re- 
verses of  fortune,  unexpected  joy ;  if  they  have  passed 
suddenly  from  an  active  life  to  one  of  repose,  or  vice 
versa,  etc.,  etc.  In  short  no  point  must  be  left  in 
the  dark,  and  every  effort  must  be  made  to  search 
out  fully  the  patient's  past  life. 

B. — Passing  next  to  the  malady  the  nature  of  which 
is  to  be  determined,  one  must  demand  of  the  rela- 
tives what,  in  their  opinion,  is  the  cause  or  probable 
cause,  moral  or  material;  what  was  the  date  and 
manner  of  its  beginning,  its  first  mental  and  bodily 
manifestations,  the  course  it  has  taken  since  its  be- 
ginning; inquiry  should  be  made  as  to  the  present 
conduct  of  the  patient,  the  nature  of  his  ideas,  his 


EXAMINATION  OF  THE  PATIENT.  531 

conversation,  sentiments,  the  acts  he  has  committed, 
the  state  of  his  organic  functions,  esi^ecially  his  di- 
gestive and  genital  functions,  and,  above  all,  his 
sleep. 

Whenever  possible,  the  writings  of  the  patient 
should  be  seen  and  compared  vi^ith  other  similar  pro- 
ductions of  various  previous  dates.  The  autographs 
of  the  insane  deserve  all  the  physician's  attention  as 
they  often  bear  the  direct  evidence  of  the  disorder  of 
their  faculties,  either  in  form  as  a  graphic  represent- 
ation, or  fundamentally  as  a  mode  of  expression  of 
delusional  ideas. 

The  interrogation  of  the  family  having  been  com- 
pleted, we  find  ourselves  in  possession  of  valuable 
data  that  permit  us  to  proceed  profitably  in  the 
examination  of  the  patient  himself. 

Examination  of  the  Patient. — It  may  happen 
that  we  have  to  deal  with  a  patient,  with  more  or 
less  fever,  or  one  suffering  from  an  acute  visceral 
disease  complicated  with  delirium ;  in  such  cases  the 
first  steps  should  be  as  with  an  ordinary  sick  patient, 
and  the  diagnosis  consists  in  determining  the  exist- 
ence of  the  organic  affection  and  specifying  the 
nature  of  the  febrile  or  vesanic  delirium  that  accom- 
panies it.  We  have  seen,  in  the  first  part  of  this 
work,  on  what  basis  rests  this  distinction,  gouerally 
easy  to  establish. 

Generally  we  have  to  do  with  an  insane  person, 
^ho  continues,  in  a  measure,  to  go  and  come,  to  live 


532  PRACTICAL  DIAGNOSIS  OF  INSANITY. 

his  usual  life,  and  who  is  still  semi-capable  of  under- 
standing what  passes  around  him  and  of  carrying  on  a 
conversation.  These  are  the  cases  therefore  we  must 
have  in  view  in  our  study. 

First^  how  to  begin  with  the, patient? — This  is,  in 
its  way,  a  very  important  question,  and  one  that 
presents  certain  difficulties.  In  ordinary  medical 
practice,  the  patient,  instead  of  fearing  the  physician's 
visit,  desires  it  with  impatience,  he  looks  to  him 
sometimes  as  to  a  saviour,  so  the  relations  between 
the  two  are  very  satisfactory.  The  peculiarity  of 
insanity  on  the  other  hand,  is  non-recognition  of 
itself,  and  the  majority  of  the  insane,  ignorant  of 
their  condition,  believe  themselves  perfectly  sound  in 
mind.  To  begin  therefore  as  a  physician,  at  least 
in  cases  other  than  those  of  profound  dementia  or  of 
violent  maniacal  excitement  rendering  the  subjects 
indifferent  to  everything  about  them,  is  to  incur  a 
great  risk,  not  only  of  spoiling  everything  and  of 
reaching  no  result,  but  also  of  having  the  patients  fall 
into  a  passion,  become  violent,  and  sometimes  receiv- 
ing insults,  threats,  and  regrettable  violence. 

How  shall  this  difficulty  be  avoided?  Some  authors 
have  proposed,  when  it  is  not  possible  to  meet  the 
patient  as  a  medical  advisor,  to  make  use  of  any 
knowledge  one  may  have  as  to  his  delusions  to  intro- 
duce one's  self  in  a  character  in  accordance  with  them. 
Is  the  patient  a  megalomaniac  who  believes  himself 
possessor  of  an  immense  fortune,  a  general,  prince, 


Sjxamin'ation  op  the  patient.  533 

or  potentate?  Then  begin  as  a  man  of  business,  wish- 
ing to  propose  a  purchase,  a  banker,  or  an  ambassador 
from  a  friendly  power.  Is  he,  on  the  other  hand,  a 
case  of  delusions  of  persecution?  Then  present  your- 
self as  a  police  officer,  a  magistrate  charged  with 
making  an  inquiry  into  his  persecutions  and  obtain- 
ing for  him  justice.  And  so  on,  each  form  of  delu- 
sion serving  as  a  basis  for  the  part  the  physician  is 
to  play.  Other  authorities,  Dr.  MacDonald  among 
others,  affirm  that  all  these  disguises  are  un- 
worthy of  the  physician,  and  should  in  no  case  be 
resorted  to;  all  the  more,  since  the  insane  often 
detect  the  imposition,  and  take  a  malicious  pleasure 
in  makinof-  the  doctor  ridiculous  in  his  assumed  char- 
acter:  as,  for  example,  the  insane  mystic  to  whom 
Dr.  MacDonald  was  introduced  as  a  Protestant 
clergyman,  and  who  mischievously  compelled  the 
poor  doctor  to  say  grace  at  meals  and  to  answer  the 
most  difficult  theological  questions.  In  fact,  we  can- 
not lay  down  any  fixed  rules  in  this  regard.  On  princi- 
ple, it  would  be  better  to  present  oneself  squarely  as  a 
physician  were  it  not  for  suffering  the  first  fire  of  the 
patient's  anger ;  it  is  rare  that  with  skill  and  patience 
one  does  not  speedily  master  his  spirit.  It  is  only 
when  it  is  impossible  to  act  otherwise  that  the  physi- 
cian ought  to  hide  his  real  personality  under  any 
disguise ;  he  should  also  guard  against  giving  way  to 
all  the  fancies  of  the  relatives,  who  under  the  foolish 
pretext  of  not  disturbing  the  patient,  sometimes  in- 
vent the  most  ridiculous  comedies,  even  going  so  far 


534  PRACTICAL  DIAGNOSIS  OF  INSANITY. 

as  to  demand  that  the  physician  should  announce  him- 
self as  a  tailor  come  to  take  his  measure,  or  as  some 
sort  of  merchant  soliciting  trade.  The  most  simple 
roles  are  always  the  best.  One  of  the  better  methods 
is  to  appear  as  a  doctor  calling  to  see  some  other 
member  of  the  family  (wife,  children,  etc.) ;  the 
health  of  such  person  is  a  convenient  subject  to  open 
upon  with  the  patient  and  conduct  the  conversation 
naturally,  and  then  lead  him  unconsciously  to  the 
subject  of  his  OAvn  health. 

Once  in  the  presence  of  the  patient,  whom  it  is 
always  w^ell  to  know  how  to  distinguish  amongst 
those  about  him  w^hen  seen  in  company  and  for  the 
first  time,  under  penalty  of  otherwise  making  regret- 
table mistakes,  one  should  avoid  a  direct  attack  of 
asking  inconsiderately  in  regard  to  his  delusions. 
Sight  should  not  be  lost  of  the  fact  that  in  this  situ- 
ation one  is  before  a  place  to  be  taken,  there  is  a 
veritable  siege  to  be  laid. 

The  discourse  ought,  therefore,  to  be  at  first  con- 
fined to  matters  of  light  importance,  and  it  is  by  a 
series  of  skilfully  managed  transitions,  taking  ad- 
vantage of  every  hint  dropped  by  the  patient,  that 
it  is,  unconsciously  to  him,  directed  to  the  patliolog- 
ical  conditions.  It  is  profitable,  moreover,  to  utilize 
these  first  few  minutes  in  the  ins2)ection  of  the  pa- 
tient, to  form  a  judgment  on  the  total  and  the  de- 
tails of  his  physique,  which  may  furnish  valuable 
indications,  and  in  some  cases  be  alone  sufiicient  for 
the  diagnosis.    Thus  microcephaly,  prognathism,  lack 


EXAMINATION  OF  THE  PATIENT.  535 

of  folds  in  the  ear,  deaf  mutism,  lisping,  and  all  mal- 
formations and  arrests  of  development  are  signs  of 
intellectual  and  moral  degeneracy ;  excessive  asym- 
metry of  the  face  should  put  us  on  our  guard  for  epi- 
lepsy ;  hemiplegia  indicates  an  apoplectic  dementia ; 
embarrassment  of  speech  by  itself  alone,  and  with 
much  more  reason  when  it  is  accompanied  with  tre- 
mor and  inequality  of  the  pupils,  is  often  sufficient 
to  cause  the  recognition  of  general  paralysis ;  very 
marked  tremor  of  the  hands  reveals  alcoholism ;  ag- 
itation, disordered  acts,  incessant  cries,  incoherence, 
animation  of  the  face  and  eyes,  denote  mania ;  de- 
pression, grief,  immobility,  hanging  head,  viola- 
ceous tint  of  the  skin,  infected  odor  of  the  breath, 
cicatrices  of  special  localities,  notably  the  head  and 
neck,  evidences  of  one  or  more  suicidal  attempts, 
indicate  melancholia;  a  gloomy,  haughty,  distrust- 
ful attitude  with  eyes  open  and  threatening  in  appear- 
ance indicates  persecutory  hallucinations;  oddity 
of  costume,  a  special  arrangement  of  the  headgear, 
hair  and  beard,  colored  ribbons,  medals  and  chap- 
lets  worn  conspicuously,  and  a  proud  and  majes- 
tic attitude,  betray  a  systematized  insanity,  especially 
megalomania;  and  so  on,  the  phj^sical  inspection 
alone,  that  is  too  often  neglected,  frequently  reveals 
interesting  particulars  that,  aided  by  information 
already  obtained,  are  sometimes  sufficient  to  make 
matters  completely  clear  to  the  observer.  It  is  well, 
at  the  same  time,  to  cast  a  glance  about  the  ajDart- 
ment  of  the  patient,  which   by  its   general  arrange- 


536  PRACTICAL  DIAGK-QSIS  OF  INSANITY. 

ment  or  that  of  certain  parts,  of  certain  pieces  of 
furniture  or  accessories,  sometimes  affords  character- 
istic indices  of  insanity. 

During  this  time  conversation  opens  the  way, 
and  one  gradually  obtains  control  of  the  patient's 
mind  so  that  the  point  is  reached  of  progressively 
leading  the  discourse  on  to  the  subject  of  his  delu- 
sions. This  arrived  at,  there  is  no  invariable  rule 
to  be  followed  any  more  than  there  is  a  methodic 
order  of  questions  to  be  asked.  Everything  is  sub- 
ordinated to  the  nature  of  the  disease  and  the  attitude 
of  the  patient.  Therefore  it  may  be  settled  as  a 
principle  that  the  course  of  the  conversation,  instead 
of  Ijeing  laid  out  in  advance  and  consisting  in  a  series 
of  pre-arranged  questions  asked  in  a  definite  order, 
should  rather  be  guided  by  the  patient  himself. 
The  physician,  without  losing  for  an  instant  his 
object  in  view,  should  let  the  j^atient  talk,  listen 
without  interrupting,  even  although  he  relates 
tedious  details,  limiting  himself  to  recalling  him  to 
his  subject  whenever  he  wanders,  and  narrowing  it 
more  and  more.  In  this  way  we  are  able  to  eluci- 
date all  the  points  of  the  problem  and  to  penetrate 
more  and  more  deeply  into  the  intimate  and  secret 
feelings  of  the  insane. 

In  any  case  whatever  it  should  never  be  forgotten 
that  there  are  two  essential  and  quite  distinct  things 
to  be  determined:  (1)  the  condition  of  the  intel- 
lectual capital,  that  is  to  say,  the  intelligence  in  a 
quantitative  point  of  view ;  (2)  the  state  of  intellect- 


EXAMINATION  OF  THE  PATIENT.  537 

ual  functioning,  that  is  to  say,  the  intelligence  in  a 
qualitative  poiijt  of  view.  The  study  of  the  first 
point  will  serve  to  indicate  if  the  psychic  faculties 
of  the  patient  are  normally  developed  or  preserved 
in  their  integrity,  or  in  other  words  whether  there  is 
or  is  not  any  congenital  or  acquired  cerebral  infirm- 
ity; the  study  of  the  second  point  will  make  certain 
whether  the  faculties,  whether  normally  constituted 
or  not,  function  incorrectly,  or  whether  there  exists 
any  insanity  and,  if  so,  of  what  kind. 

In  order  to  estimate  in  a  quantitative  point  of 
view,  the  psychic  level  of  the  subject,  we  should  use 
for  comparison,  what  we  know  from  previous  in- 
formation of  the  former  condition  of  his  faculties, 
and  compare  with  that  the  state  of  affairs  we  find 
existing,  using  as  means  of  measurement  various 
questions,  recollections  recalled,  dates  and  calculations 
skilfully  demanded,  making  the  patient  write  some 
lines,  calling  out  some  literary,  philosophical  or 
moral  appreciations  on  his  part,  all  of  which  permit 
an  estimation  as  to  the  fund  of  intelligence,  and 
especially  of  the  state  of  the  memory,  ideation,  rea- 
soning power,  judgment  and  moral  sense.  This 
important  part  of  the  problem  being  settled,  and  it 
is  generally  easily  managed,  at  least  when  the  degree 
of  dementia  or  mental  weakness  is  slight,  we  seek 
to  solve  the  second  question  which  consists  in  ascer- 
taining whether  the  patient  is  a  victim  of  insanity 
and  of  what  form. 

The  information  obtained  from  the  family,  added 

Ment.  Med,— 34, 


538  PEACTICAL  DIAGNOSIS  OF  INSANITY. 

to  that  obtained  from  inspection  and  questioning  of 
the  patient,  lias  already  sufficed  to  assure  us  that  he 
is  affected  with  some  mental  disorder.  As  regards 
the  question  whether  the  mental  trouble  amounts  to 
an  actual  insanity  or  not,  it  is  one  which,  while  easily 
solved  in  most  cases,  may  in  some  others  give  rise  to 
very  serious  difficulties;  there  is  not  indeed,  properly 
speaking,  any  absolute  criterion  of  insanity.  It 
should  be  based  mainly  on  the  condition  of  the  will 
power,  because  the  thing  of  most  supreme  importance 
is  to  find  out  if  the  patient  is  still  his  own  master  and 
controls  himself  or,  on  the  contrary,  if  he  has  lost  the 
free  control  of  his  actions  and  is  more  or  less  com- 
pletely under  the  dominion  of  his  morbid  tendencies. 
In  a  case,  moreover,  where  we  have  to  do  with  one  of 
the  exceptionally  dubious  instances  of  semi-insanity, 
the  exact  estimation  of  which  is  so  difficult,  one  ought 
always  to  either  claim  a  supplemental  inquest,  or  to 
utilize  in  consultation  the  skill  of  a  brother  physician. 
The  existence  of  insanity  established,  it  yet  re- 
mains to  determine  its  form  and,  when  we  have  to 
do  with  a  generalized  insanity,  to  ascertain  whether 
it  is  a  simple  or  a  symptomatic  or  sympathetic  form. 
This  is  the  indispensable  complement  of  the  diag- 
nosis, which  can  only  be  settled  satisfactorily  by  hav- 
ing clearly  before  the  mind  the  primary  elements 
of  mental  alienation  and  the  manner  in  which  they 
are  associated  together  to  constitute  the  various  types 
of  insanity.  Thus  a  general  disorder  of  the  activ- 
ity, excitement  or  depression,  denotes  a  condition  of 


EXAMTNTATION  OP  THE  PATIENT.  539 

mania  or  of  melancholia,  while  the  absence  of  this 
general  disturbance  indicates  partial  or  systematized 
insanity;  in  the  same  v/ay,  mobility  of  the  ideas, inco- 
herence, sensorial  and  mental  illusions,  disordered 
excitement  of  speech  and  actions,  characterize  acute 
mania;  gloomy  delusive  conceptions,  ideas  of  culpa- 
bility, of  humility,  of  ruin,  damnation,  perdition, 
hallucinations,  refusal  to  speak,  to  eat,  or  to  move, 
together  with  suicidal  tendency  are  characteristic  of 
melancholia;  systematized,  coherent  delusions,  either 
of  persecution  or  of  mysticism,  hallucinations  of 
hearing  and  disturbances  of  the  general  sensibil- 
ity, reticence  and  impulsions,  appertain  to  systema- 
tized insanity,  etc.,  etc. ;  in  a  word,  in  order  to  be 
able  to  distinguish  in  practice  the  di:fferent  forms  of 
insanity  from  each  other,  it  is  needful  that  one 
should  be  acquainted  with  the  principal  symptoms 
of  each  special  form. 

Not  losing  sight  of  this  objective  point  we  can 
proceed  to  the  interrogation  of  the  patient  and  the 
determination  of  the  peculiarities  of  his  mental  con- 
dition ;  that  is,  according  to  the  case,  the  nature 
and  intensity  of  his  delusive  conceptions,  his  hallu- 
cinations, his  intellectual,  moral,  and  affective  aber- 
rations, his  prepossessions,  desires,  projects,  path- 
ological hopes,  his  temptations  and  impulsions. 

It  is  understood  that  it  may  not  be  possible  to  lay 
down  fixed  rules  relative  to  formulas  to  be  adopted 
in  the  interrogation,  nor  consequently  to  indicate 
any  made-up  list  of  questions.     What  it  is  import- 


540  PRACTICAL  DIAG2«0SIS  OF  INSANITY. 

ant  to  keep  in  mind  is,  that  whatever  may  be  his 
condition,  it  is  needful  to  always  treat  the  patient 
with  the  greatest  politeness  and  consideration,  since, 
however  profoundly  disordered  they  may  be,  the  in- 
sane are  always  capable  of  appreciation  of  politeness 
and  consideration  shown  them.  It  is,  besides,  by 
such  means  that  we  are  able,  in  great  part,  to  obtain 
their  good  will  and  ascertain  their  mental  condition, 
the  principal  aim  of  our  proceedings.  It  is  well  un- 
derstood that  we  should  never  speak  to  a  lunatic  as 
to  a  patient,  or  let  him  suspect  that  we  consider  him 
affected  with  any  mental  trouble  whatever ;  so  it  is 
important  to  weigh  all  one's  words  with  care,  and 
particularly  to  guard  against  any  evidently  medical 
interrogations,  like  those  addressed  to  other  classes 
of  patients,  such  for  example  as, — "  Have  you  any 
ideas  of  persecution?"  "  Since  when  have  you  had 
this  embarrassment  of  speech?  "  "  Have  you  always 
had  these  hallucinations;"  etc.,  etc.  The  condition 
of  the  patient  and  the  peculiarities  of  his  disorder 
must  be  ascertained  without  any  technical  word  hav- 
ing been  pronounced,  and  without  his  suspecting 
that  he  has  undergone  a  scientific  examination  to 
find  out  whether  or  not  he  is  deranged.  I  need  not 
add  that  in  no  case  should  the  chief  part  of  the  ex- 
amination consist  in  the  queries  and  methods  of  in- 
quiry, without  any  real  import,  to  which  the  public 
and  some  magistrates  wrongly  attribute  the  value  of 
a  real  criterion,  and  which  consists  in  simple  inter- 
rogations on  the  course  of    time  or  the   respective 


EXAMINATION  OF  THE  PATIENT.  541 

value  of  different  pieces  of  money.  As  is  well 
known,  with  some  people,  the  ability  of  the  patient 
to  tell  his  age,  the  month  it  happens  to  be,  and  to 
give  correctly  the  money  value  of  a  piece  of  silver 
or  a  note  is  to  clearly  prove  that  he  is  not  insane. 

It  occasionally  happens  that  the  physician  encoun- 
ters a  patient  who  continues  voluntarily  mute  to  all 
questions,  so  that  after  having  exhausted  all  his  re- 
sources he  is  compelled  to  acknowledge  himself  van- 
quished and  to  give  up  the  interrogation.  But  this 
absolute  mutism  is,  in  medical  practice,  nothing  es- 
pecially surprising  or  discouraging,  as  it  has,  by 
itself,  a  clinical  value,  and  if  it  prevents  the  obtain- 
ing of  valuable  points  furnished  by  the  patient's 
replies,  it  is,  on  the  other  hand,  a  genuine  symptom 
which,  though  a  negative  one,  has  still  a  very  import- 
ant signification. 

Mutism,  in  fact,  is  a  special  feature  of  some  forms 
of  insanity  which  its  occurrence  therefore  tends 
consequently  to  reveal. 

Thus,  if  we  observe  a  very  depressed,  woe-begone, 
immovable  individual,  with  eyes  cast  down  and  head 
bent  on  his  chest,  whom  nothing  seems  to  move,  we 
have  here  almost  certainly  an  insane  person  affected 
with  profound  melancholia,  more  or  less  closely  ap- 
proaching stupor.  Tlie  diagnosis  will  be  assured  if 
we  find  at  the  same  time  in  the  patient  disorders  of 
the  peripheral  circulation,  that  violaceous  coloration 
of  the  skin  and  coldness  of  the  extremities  that  are 
the  external  indices  of  the  melancholic  condition. 


542  PRACTICAL  DIAGNOSIS  OF  IN'SANITY. 

If,  on  the  contrarY,  the  silent  patient  is  one  that 
meets  tlie  approach  of  the  physician  with  a  suspicious, 
offensive  manner,  who  recoils  from  him  as  from  a 
serpent,  or,  on  the  other  hand,  views  him  arrogantly 
vvith  fixed  gaze,  we  may  be  almost  certain  that  in 
this  case  we  have  an  hallucinated  lunatic  suffering 
from  systematized  insanity,  more  particularly  with 
delusions  of  persecution.  Generally,  moreover,  in 
spite  of  his  purposed  reticence,  there  will  escape  from 
him  some  significant,  insulting,  or  typical  phrase 
somewhat  of  the  following  order,  that  j^erf ectly  clears 
up  the  diagnosis :  "You  know  better  than  I."  "I 
liave  nothing  to  say  to  you."     "It  is  my  affair." 

The  physician  who  examines  a  lunatic  ought 
never  to  be  discouraged  by  rebuffs  he  encounters, 
nor  break  off  the  conversation  at  the  least  refusal  to 
respond  that  lie  meets  with.  As  a  general  rule,  the 
examination  of  the  insane,  especially  that  of  rea- 
soning and  systematized  cases,  ought  to  be  prolonged, 
as  these  patients  have  to  be  mastered  gradually ;  the 
first  quarter  of  an  hour  seldom  reveals  much,  then 
one  minute  of  the  second  may  alone  be  of  much 
greater  value;  an  hour  is  not  too  much  sometimes. 
Contrary  to  the  advice  of  most  authors,  I  believe, 
therefore,  that  it  is  necessary  to  tire  out  the  patient. 
When  he  is  compelled,  he  yields,  confesses  without 
evasion  or  restriction  and  gives  himself  completely 
to  his  interrogator.  Thus  when  one  has,  after  much 
trouble,  gained  his  confidence,  he  should  never  aban- 
don the  conversation  and  put  it  off  till  another  day, 


EXAMINATION  OF  THE  PATIENT.  643 

for  with  an  insane  person,  at  least  wlien  lie  has 
not  fully  revealed  himself,  it  is  hardly  possible  to 
take  up  the  conversation  at  the  precise  point  where 
it  has  been  left  off ;  usually  it  becomes  necessary  to 
recommence  the  whole  examination  and  to  obtain 
anew  the  former  admissions  before  pushing  the 
investigation  farther.  It  is  only  in  exceptional 
cases,  and  when  the  examination  needs  to  be  fol- 
lowed up  and  renewed,  as  in  medico-legal  examina- 
tions, that  we  can  thus  abandon  the  interrogation 
half  done,  to  be  continued  again  later. 

The  examination  of  the  patient  finished,  we  should 
proceed,  whenever  it  is  not  impossible,  to  a  rapid 
examination  of  the  great  organic  functions,  insisting 
more  especially  on  this,  if  there  is  any  reason  to  sus- 
pect any  visceral  disorder  capable  of  having  some 
relation  with  the  mental  trouble.  It  is  in  melan- 
cholic forms  and  particularly  amongst  females  with 
internal  illusions,  or  sexual  sensations,  that  it  is 
necessary  to  give  a  minute  study  to  the  great  appa- 
ratuses of  the  organism. 

When  the  examination  and  interrogation  of  the 
patient  is  completed,  the  phj'-sician  should  politely 
and  amicably  take  leave,  with  a  pleasant  word  or  a 
promise  soon  to  see  him  again. 


Cbapter  n. 

MEDICAL  ADVICE  AS  TO  THE  NECESSITY 
OF  SEQUESTRATION. 

The  diagnosis  settled  and  the  form  of  mental  de- 
rangement once  clearly  defined,  it  remains  for  the 
physician  to  give  liis  opinion  as  to  what  is  next 
advisable,  that  is,  to  pronounce  in  regard  to  the 
question  of  confinement  of  the  patient  or  not. 
Before  stating  the  considerations  that  may  permit 
him  to  decide  with  thorough  knowledge  in  this 
regard,  it  will  be  of  utility  to  call  attention  to  two 
fundamental  points,  that  seem  to  be  only  imperfectly 
understood  in  practice. 

The  first  is  that  isolation  in  a  special  establishment 
being  a  part  of  the  medical  treatment,  a  veritable 
therapeutic  agency,  it  is  to  the  physician  and  to  him 
alone,  that  the  right  to  prescribe  it  belongs,  it  being 
in  this  like  the  prescription  of  any  other  method  of 
treatment  or  medication.  It  may  be  said  in  reply 
to  this  that,  as  regards  insanity,  every  member  of 
the  community  believes  he  knows  well  enough  what 
to  do,  and  that  in  families  where  there  is  an  insane 
member,  the  relatives  will  not  leave  to  any  one  out- 
side of  their  own  number,  the  responsibility  of  de- 
ciding whether  sequestration  is  or  is  not  necessary. 
To  oppose  this  will  therefore  be  for  the  physician  to 


GENERAL  CONSIDERATIONS.  545 

pit  himself  against  est ablislied  opinions  and  to  raise  a 
thousand  objections.  They  are  well  aware,  they 
say,  that  the  patient  is  a  little  depressed  or  excited 
or  even  seems  eccentric,  his  nerves  are  out  of  order, 
but  as  for  his  being  insane,  it  is  impossible,  there  is 
clearly  an  exaggeration  here;  there  are  physicians 
who  see  insanity  everywhere.  Moreover  the  disorder 
is  not  yet  sufficiently  advanced,  it  will  be  time 
enough  to  act  later,  if  it  is  needed.  They  fear  the 
poor  man  would  rather  lose  his  head  altogether 
than  be  placed  in  an  insane  asylum  and  deprived  of 
his  liberty,  where  he  could  only  become  more  excited 
in  contact  with  raving  maniacs.  It  should  be  consid- 
ered how  he  will  lose  in  reputation  if  the  report  of 
his  sojourn  in  an  asylum  should  get  out,  the  whole 
family  would  suffer,  and  he  has  daughters  to  get 
married  off.  They  do  not  want  to  take  the  respons- 
ibility of  his  confinement  without  consulting  all 
the  members  of  his  family,  since  they  fear  he  would 
never  forgive  them  if  he  should  be  restored  to  health. 
They  reiterate  finally  all  the  old  stereotyped  tales 
about  asylums  that  are  extant  amongst  the  masses, 
who  believe  fully  tliat  patients  are  there  submitted 
to  violence  and  to  all  sorts  of  bad  treatment.  The 
above  are  the  objections  raised  usually  b}^  the  fami- 
lies, to  the  proposition  of  the  physician,  and  the 
reasons  why  they  object  to  the  asylum.  But  it  must 
be  admitted  that  if  errors  and  prejudices  still  exist 
on  the  part  of  the  public  relative  to  the  insane  and 
to  the  methods  of  treatment  suitable  for  them,  this 


546  NECESSITY  OF  SEQUESTRATION. 

is,  in  great  part,  due  to  the  fact  that  medical  men 
have  too  long  lacked  interest  in  the  matter  and  have 
voluntarily  abdicated  all  initiative  as  regards  these 
patients.  When  the  time  comes  when  every  phy- 
sician is  versed  in  the  study  of  mental  alienation,  and 
can  testify  from  his  own  observation  as  to  the  bene- 
ficial effects  of  isolation  in  the  treatment  of  insanity, 
when  he  will  assume  his  proper  function  in  cases 
where  he  is  called  and  explain,  with  full  knowledge 
of  the  subject,  to  the  friends  the  therapeutic  effi- 
ciency of  asylum  treatment,  then  the  public  will  be 
quickly  educated  and  will  abandon  its  errors  as  to 
insanity,  as  it  has  already  abandoned  those  in  regard 
to  otlier  medical  and  scientific  questions.  It  is  im- 
portant, therefore,  that  the  physician  should  never 
lose  sight  of  the  fact  that  to  him,  and  him*  only, 
belongs  the  right  to  judge  as  to  the  ne^^d  of  confine- 
ment of  an  insane  person,  and  that,  if  it  is  allowable 
to  discuss  the  possibility  of  this  measure  with  the 
families,  or  even,  at  a  pinch,  to  yield  and  make 
some  concessions,  he  should  never  abdicate  his  place 
to  the  extent  of  becoming  a  mere  figurehead,  charged 
only  with  the  responsibility  of  endorsing  with  a 
medical  opinion  a  measure  the  initiative  of  which 
appertains  to  others. 

The  second  fundamental  point  that  seems  to  me 
so  important  to  keep  in  mind,  is  that  establishments 
for  the  insane  ought  not  to  be  considered  solely  as  a 
refuge,  intended  to  prevent  the  dangerous  acts  of 
lunatics,  or  as  simple  asylums  serving  to  protect  the 


GENERAL  COXSIDEEATIONS.  547 

friends,  the  public  and  the  patients  themselves 
from  scandals  and  pathological  crimes.  It  is  unde- 
niable that  the  guaranties  they  afford  are,  in  fact, 
one  of  their  advantages ;  but  their  chief  utility,  that 
which  renders  them  indispensable,  is  that  they  real- 
ize in  principle  and  in  details  all  the  moral  and 
material  conditions  of  isolation,  the  most  efiicaceous 
and  fruitful  method  of  treatment  of  insanit}?"  in  our 
knowledge. 

"  The  insane  asylum,"  says  Esquirol,  "  is  an  instru- 
ment of  care."  It  is  not  necessary  at  this  day  to 
discuss  at  length  the  advantages  of  isolation  in  the 
treatment  of  mental  diseases.  This  therapeutic  method 
has  proved  its  value  and  is  proving  it  every  day,  and 
it  is  recognized  at  the  present  time  that  there  is  no 
better  means  with  which  to  meet  insanity.  When 
we  compare,  as  regards  the  results  obtained,  the  cases 
treated  outside  and  similar  cases  treated  in  special 
establishments,  it  cannot  but  be  recognized  that 
sequestration,  far  from  being  injurious,  offers  by 
itself  alone  the  best  opportunity  for  recovery  that  is 
available  to  the  patient.  It  is  this  double  usefulness 
of  isolation,  not  only  as  a  protective  measure,  but 
also  and  especially  as  a  precious  therapeutic  resource, 
that  the  physician  should  keep  in  mind  when  called 
on  for  his  opinion  in  this  regard. 

We  will  now  see  what  are  the  principal  consider- 
ations that  should  occur  to  the  practitioner  in  forming 
his  medical  opinion  as  to  the  necessity  of  this  measure. 

These  considerations  are  of  two  orders:  (1)  those 


548  NECESSITY  OF  SEQUESTRATION. 

relative  to   the  patient;    (2)   those   relative   to  the 
disease. 

(1)  Considerations  Relative  to  the  Patient. — As 
regards  the  patient,  it  is  first  necessary  to  consider 
his  situation  as  regards  his  family,  and  especially  as 
regards  his  social  position.  If  he  has  no  relatives 
really  attached  to  him  and  ready  to  devote  themselves 
to  caring  for  him  to  the  extent  of  meeting  the  tre- 
mendous difticulties  incident  to  his  care  at  home,  if 
he  is  alone  or  surrounded  only  with  indifferent 
or  mercenary  people,  it  is  evident  that,  whatever 
may  be  his  condition,  his  confinement  in  a  special  es- 
tablishment is  necessitated  as  the  most  favorable 
measure  for  the  treatment  of  his  disorder.  On  the 
other  hand,  if  the  patient  belongs  to  the  middle  or 
poorer  classes,  we  are  also  compelled  in  most  cases, 
apart  from  all  other  considerations,  to  have  him  sent 
to  the  asylum,  since  he  is  an  expense  and  trouble  to 
his  friends  who,  busied  with  their  daily  occupations 
would  find  it  an  impossibility  to  properly  watch  over 
and  care  for  him,  and  who  besides  this,  deprived  as 
they  are  of  resources,  could  not  undergo  the  large 
expense  entailed  by  methodic  home  treatment.  In 
the  wealthy  class,  on  the  contrary,  the  social  condi- 
tion of  the  patient  may  necessitate  outside  treat- 
ment, when  it  is  practicable.  Then,  on  account  of 
these  various  social  differences,  we  m^ay  say  a  priori^ 
that  all  the  poorer  class  of  patients  ought  to  be  sent 
to  asylums,  and  that  the  treatment  at  home  can  only 
be  realized  when  it  is  practicable  amongst  the  upper 
classes  of  society. 


SITUATION  OF  THE  PATIENT.  549 

(2)  Considerations  Deduced  from  the  Disease. — 
The  considerations  deduced  from  the  disease,  mainly 
relate:  A. — to  its  degree  of  curability;  B. — to 
the  more  or  less  dangerous  character  of  the  morbid 
tendencies  it  produces. 

A. — In  every  case  of  acute  derangement,  espe- 
cially an  attack  of  mania  or  melancholia,  that  is  of  a 
curable  form,  isolation  should  be  practiced  as  early 
as  possible,  because  it  has  been  irrefutably  demon- 
strated by  experience  and  proven  that  the  insanity 
has  not  only  ten  times  less  chances  of  recovery  at 
home  than  in  a  special  establishment,  but  also  that 
an  attack  of  insanity,  not  specially  treated  but  left 
to  itself  in  an  asylum,  recovers  more  quickly  than 
would  the  same  case  treated  and  watched  outside  of 
an  institution. 

In  the  interest  of  the  patient,  which  should 
be  above  all  other  considerations,  the  physician 
ought  therefore  to  advise  isolation  in  any  case  that 
affords  chances  of  cure,  and  should  endeavor  to  over- 
come the  opposition  of  the  family,  who,  from  very 
natural  but  ill  advised  sentiments  of  affection  and 
devotion,  are  always  hesitant  about  separation,  and 
have,  moreover,  very  frequently  unjustifiable  preju- 
dices against  asylums,  which  they  think  in  their  ig- 
norance will  aggravate  the  patient's  condition.  It  is 
certainly  very  hard  with  members  of  the  family  who, 
making  no  difference  between  insanity  and  ordinary 
ailments,  are  prepared  to  devote  themselves  to  the 
patient  and  to  surround  him  with  the  tenderest  and 


550  NECESSITY  OF  SEQUESTEATION. 

most  affectionate  care,  to  make  them  understand  tbat 
their  own  influence  and  contact  are  themselves  the 
greatest  obstacles  to  his  recovery.  Nothing  is  more 
true,  notwithstanding,  and  every  one  acquainted 
with  the  treatment  of  the  insane  is  well  aware  of  the 
injurious  influence  usually  exercised  on  the  patient's 
disorder  by  the  intercourse  with  friends,  in  spite  of 
their  intelligence  and  manifest  devotion.  The  phy- 
sician ought  therefore  to  formally  counsel  the  placing 
of  the  patient  in  an  institution,  in  every  case  suscep- 
tible of  cure  or  at  least  of  amelioration.  It  is 
important  to  add,  however,  that  this  step  should  be 
taken,  not  after  the  lapse  of  some  time  or  after  more 
or  less  prolonged  delay  and  temporizing,  but  imme- 
diately, as  soon  as  possible  after  the  beginning  of  the 
disorder,  as  asylum  treatment  is  the  more  effective 
the  earlier  it  is  resorted  to.  The  friends  almost  al- 
ways object  to  this  view ;  they  wish  to  gain  time,  to 
have,  so  to  speak,  their  hand  forced  by  the  progress 
of  the  disease;  a  detestable  practice,  which,  although 
originating  in  a  kindly  feeling,  does  an  irreparable 
wrong  to  the  patient,  and  every  day  peoples  the 
asylums  with  incurables  who  might  readily  have 
recovered  had  they  been  sent  there  sooner.  In  the 
face  of  this  almost  general  opposition  the  medical 
adviser  ought  therefore  to  insist,  to  plead  the 
patient's  cause,  and,  if  necessary,  to  call  in  the  aid 
of  counsel  whose  formal  opinion  may  add  its  weight 
to  his  own  advice. 

In  cases  of  chronic  and  incurable  alienation,  isola- 


CUEABILITT  OF  THE  DISEASE.  551 

tion  is  not  so  absolute  a  necessity,  at  least  in  a 
therapeutic  point  of  view,  but  the  need  exists  in  these 
cases  also  on  account  of  considerations  of  family  and 
social  order  arising  from  the  nature  of  the  case  which 
may  render  this  measure  necessary.  In  the  first  rank 
of  these  may  be  reckoned  the  more  or  less  dangerous 
character  of  the  morbid  tendencies. 

B. — Whatever  may  be,  indeed,  the  degree  of 
curability  of  the  mental  disease,  or  whatever  the 
social  condition  of  the  patient,  it  is  absolutely  neces- 
sary to  have  recourse  to  sequestration  whenever 
there  exists  any  evident  tendency  to  dangerous  acts. 
In  such  cases,  no  matter  what  opposition  the  friends 
may  offer,  it  is  the  strict  duty  of  the  phj^sician  to 
assert  the  urgency  of  isolation.  It  is,  therefore,  very 
important  as  we  see  for  him  to  be  able  to  recognize 
the  dangerous  forms  of  mental  derangement.  In 
theory  this  distinction  seems  rather  easy,  but  noth- 
ing is  more  difficult  practically,  and  in  the  long  and 
brilliant  discussions  that  have  taken  place  on  this 
subject  in  the  Medico-Psychological  Society'',  accord 
was  had  on  only  one  point,  namely :  the  difficulty  in 
determining  absolutely  whether  a  lunatic  is  or  is  not 
dangerous. 

In  fact  it  is  hardly  agreed  on  the  one  hand  as  to  the 
signification  to  be  given  to  the  word  "dangerous," 
and  on  the  other  hand  every  lunatic,  whatever  his 
mental  condition  may  be,  is  capable  of  beconnng 
dangerous  at  any  moment.  All  are  agreed  that  an 
individual  who  has  tendencies  to  murder,  suicide, 


552  NECESSITY  OF  SEQUESTRATION. 

theft,  arson,  or  excessive  prodigality,  is  a  dangerous 
person,  but  all  Avill  not  say  the  same  of  one  who 
limits  himself  to,  for  example,  refusing  medicine 
prescribed  for  him,  or  who  unconsciously  exhibits 
his  genital  organs  in  public,  or  utters  in  society  and 
before  children  obscene  words  and  indecent  remarks. 
There  is  much  matter  for  discussion  here,  but  we 
must  limit  ourselves  to  showing  how  difficult  it  is  to 
specify  clearly  whether  a  lunatic  is  or  is  not  dangerous, 
either  to  society,  to  property,  to  his  family  or  himself. 

Nevertheless,  this  distinction,  which  lacking  a 
precise  criterion  cannot  be  formulated  in  practice  in 
an  absolute  manner,  is  rendered  possible  to  a  certain 
extent  by  the  attentive  study  of  the  habitual  ten- 
dencies in  each  form  of  derangement. 

In  the  mental  types  we  have  studied  under  the 
head  of  infirmities,  and  which  include  the  dis- 
harmonies, neurasthenias,  phrenasthenias,  mental 
weaknesses,  imbecility,  idiocy,  cretinism,  and  simple 
dementia,  the  patients  are  usually  inoffensive,  and 
consequently  do  not  absolutely  require  sequestration. 

It  must  not  be  forgotten,  nevertheless,  that  a 
certain  number  of  them  are  inclined,  from  their 
impulsiveness,  and  their  lack  of  consciousness  to 
certain  illegal  acts,  such  as  criminal  assaults,  theft, 
arson,  and  that  they  sometimes  come  before  the 
courts  to  answer  more  or  less  serious  charges. 

Most  general  2)a'ralytics, — I  speak  of  those  suf- 
fering from  simple  paralytic  dementia, — are  also 
inoffensive,   like  the  ordinary  dements,  with  whom 


CTJRAEILITT  OP  THE  DISEASE.  553 

they  have,  in  this  point  of  view,  many  analogies. 
But  the  case  is  different  with  those  in  whom  the 
paralytic  dementia  is  associated  with  a  more  or  less 
pronounced  maniacal  condition.  These  j)atients, 
it  is  true,  only  exceptionally  commit  assaults  or 
make  attempts  at  homicide;  but  if  in  their  insanity 
they  respect  human  life,  they  have  on  the  contrary 
no  regard  for  the  property  of  others  or  their  own 
interests.  Some,  especially  in  the  beginning,  in  what 
we  call  the  medico-legal  period,  waste  their  fortune 
and  that  of  their  family  on  all  sides  in  foolish  specu- 
lations, inconsiderate  purchases,  excessive  prodigal- 
ity, and  donations  of  every  kind ;  others,  erotic  to 
the  highest  degree,  exhibit  their  genital  organs  in 
public,  and  commit  the  most  obscene  acts;  many, 
finally,  are  guilty  of  indelicacies  and  petty  thefts. 
It  is  noteworthy  that  the  majority  of  general  para- 
lytics legally  confined  in  the  great  cities  have  been 
arrested  in  the  streets  for  not  having  paid  for  the 
use  of  a  carriage  they  have  been  riding  in  for  many 
hours,  or  for  having  stolen  from  a  shop,  without 
precaution  and  with  the  candor  of  unconsciousness, 
some  trifling  object,  such  as  a  cheap  umbrella,  a 
pair  of  shoes  or  trousers,  a  bunch  of  cabbage,  an 
Qgg^  or  some  sweetmeat  of  little  vahie.  AVhen 
general  paralysis  is  accompanied  by  insanity  of  the 
melancholic  type,  the  danger  is  less  great,  at  least 
to  the  public,  but  the  patient  may  be  more  or  less 
suicidally  inclined. 

IIknt,  M£0.—>35, 


554  NECESSITY  OF  SEQUESTRATION. 

In  simple  melancliolia  also  the  patients  are  gener- 
ally inoffensive,  especially  those  who  do  not  react 
actively  and  whose  depression  is  very  profound. 
It  should  not  be  forgotten,  nevertheless,  that  some 
of  them  are  dangerous,  not  so  much  perhaps  to 
others,  but  to  themselves,  and  that  it  is  sometimes 
verj^  hard  to  prevent  them  attempting  to  carry  out 
their  suicidal  ideas. 

Besides  these  mental  disorders  in  which  we  find 
the  patients  often  inoffensive  but  susceptible  of  be- 
cojjsiing  dangerous  at  times,  there  are  others,  on  the 
contrary,  where  the  proposition  is  reversed,  where 
the  patients  are  usually  dangerous  and  only  excep- 
tionally harmless ;  of  this  class  are :  mania,  princi- 
pally some  of  its  varieties,  double  form  insanity, 
hysterical  insanity,  alcoholic  insanity,  and  particu- 
larly the  systematized  insanities  and  epileptic  insanity. 

In  acute  mania,  the  patients  excited  and  propelled 
by  an  irresistible  desire  for  movement  and  action  are 
generally  disorderly  and  dangerous.  It  is  mainly 
violence  and  sudden  destructive  behavior  that  is  to  be 
feared  on  their  part,  rather  than  tendencies  to  homi- 
cide which  they  are  incapable  of  planning.  But 
maniacal  excitation,  or  subacute  mania,  still  more 
than  acute  mania,  renders  its  victims  dangerous. 
One  has  only  to  refer  to  the  description  given  of  this 
form  of  mental  disease  to  realize  all  the  intelligence, 
astuteness,  and  knavery  tliat  these  patients  employ 
in  the  service  of  their  perverse  instincts.  With  ap- 
parent sanity  or,  at  least,  with  apparent  conservation 


THE  DANGEROUS  INSANE.  555 

of  their  intellectnal  faculties,  they  make  out  to 
pass  for  sane  individuals  with  the  public  and  thus 
finding  means  to  make  tlieir  calumnies  and  their 
Machiavelian  inventions  seem  true,  they  are,  j^er- 
haps,  with  the  moral  lunatics,  the  worst  of  all  the 
insane. 

It  is  precisely,  moreover,  because  hysterical  and 
double  form  insanity  in  the  periods  of  excitement, 
are  frequently  made  up  of  maniacal  excitation  and 
reasoning  mania,  that  the  patients  suffering  from 
these  forms  are  in  the  same  way  so  dangerous. 

In  acute  and  subacute  alcoholic  insanity  the  tend- 
encies to  violence,  homicide,  and  especially  to  sui- 
cide are  very  frequent.  It  is  known,  in  fact,  that 
under  the  influence  of  hallucinations  causing  in 
them  a  panic  terror,  the  most  of  these  patients  flee 
wildly  from  imaginary  enemies  and  often  end  in 
throwing  themselves  out  of  an  upper  window  or  into 
the  river  to  escape  them. 

It  is  especially,  however,  in  the  systematized  in- 
sanities and  in  epileptic  insanity  that  we  meet  with 
the  really  dangerous  lunatics. 

As  regards  the  systematized  insanities,  whatever 
the  form  of  the  delusions,  really  offensive  tendencies 
are,  so  to  speak,  constant  in  them.  The  mystics, 
besides  their  practices  of  fasting,  asceticism,  and  self 
inflicted  violence  even  to  the  extent  of  more  or  less 
serious  mutilations,  often  attempt  the  life  of  others 
in  obedience  to  the  duty  that  inspires  them.  Some 
believe  they  have  received  from  heaven  a  mission  to 


556  NECESSITY  OF  SEQUESTRATION. 

Strike  doAvn  some  great  personage,  who  they  believe 
represents  the  evil  on  the  earth ;  others,  alwavs  with 
the  idea  of  pleasing  God,  renew  the  sacrifice  of 
Abraham  and  destroy  their  own  children. 

The  megalomaniacs,  those  systematized  insane  who 
believe  themselves  to  be  kings,  dukes,  princes,  or 
possessors  of  immense  fortunes,  are  often  equally 
dangerous.  It  is  not  at  all  rare,  in  fact,  to  see  them, 
urgently  claim  their  supposed  riches  and  titles, 
either  from  the  public  authoiities  or  from  well 
known  bankers,  and  to  commit  violence  when  refusal 
is  made  to  their  morbid  pretensions. 

Of  all  the  cases  of  systematized  insanity  those 
with  delusions  of  persecution  are  the  most  danger- 
ous. The  greater  part  of  the  pathological  crimes 
reported  in  the  journals  of  the  day  are,  in  fact,  com- 
mitted by  these  patients.  This  is  readily  under- 
stood. So  far  as  their  delusions  are  not  yet  fully 
systematized,  so  far  as  they  limit  themselves  to  such 
indefinite  locutions  as  the  following:  "Some  one 
wishes  me  ill,"  they  are  but  little  to  be  feared.  At 
the  most  they  then  confine  themselves  to  complain- 
ing to  the  police  or  magistrates  of  the  persecutions  to 
which  they  are  subjected.  But  from  the  time  their 
delusion  becomes  systematized,  from  the  day  when 
they  give  features  and  a  name  to  the  person  who  does 
them  harm,  from  that  day  they  become  essentially 
dangerous.  As  Lasegue  says,  they  are  no  longer 
persecuted  but  persecutors.  They  are  infuriated 
with  their  self-styled  enemies  and  have  no  rest  until 


THE  DANGEROUS  INSAISTE.  557 

they  have  smitten  them.  They  continue  to  be  es- 
sentially dangerous  in  the  asylums ;  usually  their  ill 
will  is  directed  against  the  physicians,  whom  they 
accuse  of  confining  them  "Illegally,  of  tormenting 
them,  subjecting  them  to  the  action  of  electricity 
etc.,  etc.  The  list  of  asylum  physicians  killed  or 
attacked  by  these  patients  is  already  lamentably 
long,  and  no  year  passes  without  this  sad  martyr- 
ology  being  increased  by  some  new  name.  We 
should  never  lose  sight  therefore  of  the  fact  that  the 
persecutory  insane  are  essentially  dangerous,  there 
should  be  in  their  case  no  hesitation,  they  should 
be  rigorously  sequestrated. 

Man}'  of  the  epileptics,  at  the  time  of,  and  partic- 
ularly after,  their  attacks  are  likewise  seized  with  a 
blind  furor  during  which  they  unconsciously  attack 
anyone  near  them,  or  commit  criminal  acts,  having 
afterward  no  memory  of  what  they  have  done, 
which  is,  as  we  are  aware,  the  peculiarity  of  this 
convulsive  neurosis. 

I  stop  with  this  enumeration,  which  though  im- 
perfect, may  serve  to  practically  show  in  what  classes 
of  cases  a  patient  is  or  is  not  dangerous.  It  seems 
to  me,  however,  that  it  is  possible  to  be  still  more 
exact,  and  that  there  is  one  symptom,  which,  without 
being  an  absolute  criterion,  yet  indicates  nearly 
always  when  it  exists,  the  dangerous  forms  of  mental 
alienation.  This  symptom  is  hallucinations^  espe- 
cially those  of  hearing.  In  my  opinion, — and  I  believe 
it  is  hardly  possible  to  formulate  any  indication  more 


558  NECESSITY  OF  SEQUESTRATION, 

applicable  in  practice, — every  insane  person  who  has 
cieaiij  defined  auditory  hallucinations  is  a  danger- 
ous lunatic,  and  should  accordingly  be  put  in 
confinement. 

To  sum  up,  the  medical  opinion  as  to  the  neces- 
sity of  sequestration  should  be  based  on  a  certain 
number  of  considerations  the   chief  of  which   are: 

(1)  the  social  condition  and  situation  of  the  family; 

(2)  the  degree  of  curability  of  the  disease ;  and  (3) 
the  more  or  less  dangerous  character  of  the  morbid 
tendencies. 


(Tbapter  IFHII.* 

THE   TREATMENT   OF   INSANITY. 

The  treatment  of  insanity  comprises  the  prophy- 
lactic or  preventive  treatment,  and  the  direct  or 
curative  treatment. 

I.— PREVENTIVE  TREATMENT. 

The  prophylactic  or  preventive  treatment  consists 
in  the  prevention  of  insanity  in  individuals  who  are 
predisposed  to  it.  Precise  rules  in  this  regard  cannot 
be  laid  down ;  it  consists  mainly  in  the  resources  of  a 
proper  hygiene  and  a  judicious  moral  direction.  To 
specially  watch  over  the  infancy  of  the  predisposed, 
to  manage  them  v/ith  kindness  and  firmness,  not  to 
spoil  them,  to  avoid  in  their  education  any  excessive 
mental  application,  the  more  since  they  often  exhibit 
a  marvellous  precocity ;  to  combat  their  bad  tenden- 
cies and  their  evil  instincts,  their  nascent  passions ; 
to  choose  for  them,  by  preference,  the  calm  and 
quiet  life  of  the  country ;  to  prescribe  bodily  exercise 
and  the  avoidance  of  violent  moral  emotions ;   later, 

*  Chapter  III  of  the  original  work,  on  the  placing  of  the  insane  in 
asylums,  is  mainly  made  up  of  practical  statements  and  comments 
on  the  law  of  commitment  in  France,  which  are  of  especial  value  to 
French  readers  only.  It  has  accordingly  been  omitted,  together  with 
the  closing  chapter  on  the  civil  code  in  its  bearings  on  insanity,  in  the 
present  translation. 


5 GO  TEEATMENT  OF  INSAJSTITY. 

to  fortify  thein  against  their  first  passional  impulsions, 
against  tlieir  tendencies  to  excess,  irregular  living, 
or  debauchery ;  to  put  off  marriage,  or,  on  the  other 
hand,  to  hasten  it  in  some  rare  cases  where  heredity 
is  not  to  be  feared  in  the  descendants ;  to  watch  at- 
tentively, in  females,  the  evolution  of  the  great 
events  of  sexual  life,  puberty,  menstruation,  preg- 
nancy, menopause;  finally,  to  lessen  as  much  as 
possible  the  evil  effects  of  degeneracy,  to  interdict 
certain  unions  and  to  favor  happy  crossings  of  blood ; 
such  are  the  general  principles  that  should  guide  us 
in  the  preventive  treatment  of  insanity.  Every 
case,  moreover,  has  its  own  special  indications  of 
which  it  is  necessary  to  take  account. 

II.— CURATIVE  TREATIVIENT. 

We  will  divide  the  curative  treatment  into  gen- 
eral agents  or  systems  and  special  agents. 

1. — General  Agents. 
Isolation. 

The  fundamental  principle  of  the  treatment  of  the 
insane  is  isolation.  This  consists  in  separating 
the  patient  from  his  habitual  surroundings,  from 
contact  with  persons  and  things  familiar  to  him, 
amongst  whom  he  lives,  and  where  his  disorder  had  its 
birth  and  development.  Nothing  is  worse  than  the 
retention  of  the  patient  in  his  own  dwelling,  and  the 
continuation  of  his  stay  amidst  his  family.     There 


SPECIAL  ESTABLISHMENTS.  561 

is,  in  such  case,  the  influence  of  the  family  on  the  one 
hand,  an  influence  that  is  injurious  and  prevents  or 
delays  the  cure;  and  on  the  other  hand  the  influence 
of  the  patient  upon  his  family,  which  is  not  less 
hurtful,  and  sometimes,  when  there  are  children, 
actually  dangerous.  Moreover  we  must  take  into 
account  the  danger  from  an  insane  person,  either  to 
himself  or  to  society,  against  which  his  situation 
with  his  family  affords  only  very  insufficient  guaran- 
tees. Isolation  is,  therefore,  a  measure  of  security 
and  a  powerful  therapeutic  agency. 

Isolation  may  be  in  a  special  establishment,  in  an 
agricultural  colony,  or  a  stranger  family,  in  a 
country  house  or  in  a  hydrotherapeutic  establish- 
ment.    Travel  is  also  a  means  of  isolation. 

Special  JEstahlishments. — Isolation  should,  as  a 
rule,  be  secured  in  a  special  establishment,  either  a 
public  or  private  asylum,  and  in  the  great  majority 
of  cases,  recourse  must  be  had  to  this  radical  meas- 
ure as  preferable  to  any  other.  The  asylum,  "that 
instrument  of  cure  "  as  Esquirol  calls  it,  unites,  in 
fact,  all  the  conditions  of  the  care  of  the  insane,  for 
whom  it  was  constructed.  There  the  patient  under- 
goes, almost  in  spite  of  himself,  from  the  moment 
of  his  entrance,  the  salutary  effects  of  appropriate 
organization,  good  hygiene,  fixed  rules,  disci])line,  of 
a  hierarchy  of  which  he  has  constantly  under  his  eyes 
the  examples,  and  at  the  same  time  he  is  under  an 
active  surveillance  and  placed  in  the  hands  of  expe- 


562  TREATMENT   OF  INSAXITY. 

rienced  sj^ecialist  physicians,  more  able  than  anyone 
else  to  direct  in  a  rational  manner  the  treatment  of 
his  disease. 

Farm  Colonies.  Family  System,. — Confinement 
in  a  special  establishment  cannot  be  made,  neverthe- 
less, an  absolute  rule,  and  in  some  cases  recourse 
may  be  had  to  other  modes  of  isolation,  such,  for 
example,  as  the  so-called  family  care.  This  mode 
practically  presents  itself  under  three  forms:  the 
colony  annexed  to  an  asylum;  the  independent 
colony;  and  the  private  residence. 

Colonies  attached  to  asylums  (German  system) 
exist  chiefly  in  Germany  (Alt  Scherbitz  in  Prussian 
Saxony ;  Slup,  near  the  asylum  at  Prague ;  Ellen,  near 
that  of  Bremen ;  Ilten  in  the  vicinity  of  Hanover) . 
These  colonies  are  designed  to  afford  the  insane  open- 
air  life  and  work  in  the  fields.  In  some  of  them, 
as  at  Clermont-sur-Oise  in  France,  the  patients  live 
together  in  a  sort  of  farm  asylum ;  in  others,  as  at 
Ilten,  they  are  placed  singly  among  the  country 
people  who  lodge  and  board  them  for  a  moderate 
compensation.  This  system  evidently  is  applicable 
only  to  certain  classes  of  the  insane,  carefully  selected 
by  the  physicians  mainly  from  among  the  chronic 
cases  and  the  convalescents.  The  nearness  of  the 
asylum  moreover  permits  them  to  be  readily  secluded 
on  the  least  outbreak,  and  watchfulness  is  not 
relaxed. 

The  independent  or  autonomous  colonies  (Belgian 


FAMILY  SYSTEM.  563 

system)  differ  from  the  above  only  in  that  they  are 
not  connected  with  asyhims.  The  type  of  these  in- 
stitutions is  reahzed  in  the  old  Belgian  colony  of 
Gheel  which  dates  from  time  immemorial,  and  which 
has  been  justly  called  the  Mecca  of  Alienists,  on  ac- 
count of  visits  for  study  that  it  is  constantly  receiv- 
ing. There  the  insane,  to  the  number  of  nearly  two 
thousand,  are  scattered  through  a  commune  of  over 
ten  thousand  hectares,  the  chief  village  of  which 
alone  has  five  thousand  inhabitants.  These  insane 
are  divided  into  pensionnaires  who  live  with  hotes 
(boarding  masters),  and  indigents  who  are  cared  for 
by  nourriciers.  A  central  infirmary  is  used  for 
patients  under  observation,  also  for  such  as 
require  watching  and  special  attention.  A  similar 
colony  was  founded  in  1884  at  Lierneux  in  the  Belgian 
Ardennes,  and  became  very  prosperous  within  a 
short  time.  The  autonomous  colonies,  excellent  as 
establishments  of  refuge,  leave  much  to  be  desired 
as  places  for  treatment. 

In  the  private  house  or  individual  family  isolation 
(Scotch  system)  the  insane  are  also  placed  out  among 
families  of  a  farming  community ;  but  here  this  is 
purely  individual,  and  there  is  nothing  that  recalls 
the  reunion  of  the  insane  in  agglomerated  colonies. 
This  method  is  little  known  in  France.  In  England 
it  forms  a  part  of  the  cottage  system,  but  is  scarcely 
used  except  for  patients  in  easy  circumstances.  In 
Scotland,  on  the  other  hand,  it  is  practised  on  a 
large  scale  under  the  name  of  the  "private  dwelling 


564  TREATMJENT  OF  nfSANITY. 

system,"  and  it  was  there  extended  on  Jan.  1,  1888, 
to  2,270  pauper  insane,  and  to  132  non  j^aupers,  or  to 
22.8  percent,  of  all  the  insane  in  Scotland.  The 
private  dwelling  system,  in  spite  of  its  real  advantages 
in  point  of  view  of  the  material  and  moral  conditions 
of  life  of  the  patients,  as  well  as  in  that  of  economy 
to  the  state,  can  hardly  be  applied,  except  to  inof- 
fensive and  incurable  lunatics.  Even  under  this 
restriction  its  extension  in  the  various  countries 
would  have  good  results  in  clearing  the  asylums  of  a 
multitude  of  incurables  that  encumber  them,  and  in 
restoring  these  establishments  to  their  true 
function, — that  of  hospitals  for  treatment.  The 
interesting  work  of  M.  Fere  (Paris,  1889)  may 
be  consulted  profitably  with  reference  to  all  the 
questions  relative  to  the  isolation  of  the  insane  out- 
side of  the  asylums. 

Residence  in  the  Country. — Isolation  in  a  country 
house  is  still  the  preferable  mode  of  treatment,  in 
default  of  internement.  It  is  also  that  most  willingly 
adopted  by  the  friends,  in  order  to  avoid  at  once  the 
formalities  and  disagreeable  consequences  of  entry 
into  an  asylum  and  of  living  with  an  insane  person. 
Unfortunately,  it  is  a  difficult  system  of  treatment 
to  realize  in  a  perfectly  satisfactory  way,  and  is, 
moreover,  very  exj^ensive.  The  rule  to  follow  in 
such  case  consists  essentially  in  organizing  the 
country  house  on  the  basis  of  a  private  asylum,  of 
which  it  is  practically  the  application  for  a  single 


HTDKOTHERAPEUTIC  ESTABLISHMENTS.  565 

patient.  To  the  specialist  physician  therefore  belongs 
the  right  of  disposing  and  choosing,  both  in  total 
and  in  details  the  future  residence  of  the  patient. 
He  must  not  lose  sight  of  the  following  three 
principal  points:  (1)  not  to  permit  the  family  to  live 
with  the  patient  and  -to  separate  them  as  much  as 
possible  from  each  other,  either  in  the  same  house  or 
in  different  dwellings;  (2)  to  keep  exclusively  to 
himself  the  moral  and  material  direction  of  the 
treatment  in  all  its  details;  (3)  to  insure  for  the 
patient,  together  with  competent  and  devoted  care, 
a  strict  surveillance,  continuous  and  intelligent,  by 
individuals  really  skilled  in  this  work,  which  demands 
numerous  and  especial  qualifications.  With  such  an 
organization  a  certain  number  of  insane  melancholiacs, 
paralytics,  degenerates,  etc. ,  can,  without  doubt,  be 
treated  in  a  house  in  the  country,  either  from  the 
beginning  or  after  a  prior  sedative  sojourn  in  a 
special  establishment. 

Hydr other apeutic  Establishinents. — The  insane  in 
the  beginning  of  their  disease,  or  those  considered  as 
non-dangerous,  are  sometimes  taken  and  treated  in  a 
water  cure  establishment.  In  theory,  this  treatment 
has  nothing  objectionable  in  itself,  and  it  is  in  any 
case  preferable  to  treating  the  patient  at  home;  but 
it  must  be  kept  in  mind  that  it  is  hardly  applicable 
except  to  nervous  and  semi-deranged  cases,  and  not 
to  lunatics  properly  so-called,  for  whom  the  lack  of 
control  and  discipline,  the  too  great  liberty,  the  fre- 


566  TREATMENT  OF  I]S"SA1S"ITY. 

quent  contact  with  relatives,  and  the  absence  of  a 
methodical  surveillance,  render  the  situation  an  ob- 
jectionable one  and  not  free  from  danger.  Neuras- 
thenics, hysterical  cases,  certain  nielancholiacs,  and, 
in  a  general  way,  the  peaceable  and  inoffensive  luna- 
tics whose  malady  may  be  favorably  influenced  by 
hydrotherapy,  may  nevertheless  derive  real  benefit 
from  this  method  of  treatment. 

I  will  limit  myself  to  merely  mentioning  the 
placing  of  the  insane  in  the  care  of  a  religious  com- 
munity, a  measure  resorted  to  by  some  families  in 
case  of  female  patients  of  harmless  character. 
Without  exception  this  mode  of  isolation  offers  noth- 
ing but  inconveniences. 

Travel. — Travel  is  an  efficacious  therapeutic 
agency  in  mental  derangement,  and  at  the  same  time 
is  a  salutary  means  of  diversion.  By  removing  the 
patient  from  his  usual  surroundings  it  corresponds 
indeed  to  the  very  principle  of  treatment,  isolation, 
while  at  the  same  time  it  causes  moral  and  physical 
distractions  that  react  favorably  on  the  mind  of  the 
patient.  Specially  recommended  by  Esquirol  and 
some  of  his  students,  who  had  obtained  good  results 
with  it,  it  is  less  utilized  at  the  present  on  account 
of  its  inconveniences  and  the  dangers  to  which  it 
may  give  rise.  Without  rejecting  it  in  principle,  it 
is  well  to  use  it  only  with  prudence,  and  surrounded 
with  sufficient  precautions.  Thus  certain  morbid 
forms,    notably   those  in    which   the    patients    are 


TRAVEL.  56 1 

usually  dangerous,  are  absolutely  incompatible  with 
this  mode  of  treatment.  It  suffices  to  say,  that  save 
in  rare  exceptions,  we  should  never  take  on  journeys 
maniacs  in  their  acute  stage,  epileptic  insane,  cases 
of  persecutory  insanitj^,  and  hallucinated  cases  in 
general.  On  the  other  hand,  traveling  is  very  suit- 
able in  melancholic  cases,  especialh'^  the  beginning  of 
subacute  melancholia,  not  only  because  it  affords  a 
greater  freedom  for  the  patients,  but  also  because 
they  are  the  more  susceptible  of  being  favorably 
affected  by  moral  treatment.  With  them  the  trip 
•acts  as  a  curative  agency  and  may  itself  cause  a  cure 
or  at  least  a  notable  improvement  in  the  symptoms. 
We  may  employ  it  also  in  some  chronic  insanities 
with  subjects  more  or  less  inoffensive,  but  in  these 
cases  it  is  only  a  means  of  diversion  capable  at  the 
most  of  producing  a  relative  sedation.  Whatever  the 
morbid  form  and  the  end  proposed,  the  physician 
ought  never  to  advise  or  permit  an  insane  person  to 
travel  except  on  condition  that  the  patient  should  not 
be  accompanied  by  any  of  his  nearest  friends ;  and  that 
the  direction  of  the  trip  should  be  by  an  experienced 
person  in  preference  to  a  young  physician ;  finally, 
that  all  precautionary  measures  should  be  taken  to 
prevent,  as  far  as  possible,  any  disagreeable  events 
or  accidents.  It  is  well  also  to  take  the  patient  a 
sufficient  distance,  often  even  out  of  the  country, 
and  also  to  frequently  change  his  residence;  and, 
finally,  it  is  needful  that  the  trip  should  be  long 
enough,  some  months  or  even  years,  according  to  the 


568  TREATMENT  OF  INSAinTY. 

case,  and  if  it  seems  to  produce  any  good  effect,  it 
is  advisable,  to  prolong  it  till  convalescence  is 
firmly  established. 

Non-Bestraint. 

Among  the  general  systems  that  have  been  pro- 
posed in  the  treatment  of  tbe  insane,  it  is  well  to 
cite  those  designed  to  modify  whatever  there  may 
be  of  rigor  in  the  regime  of  special  establishments  for 
the  insane. 

The  system  of  02?en  door  asylums  is  of  this  kind. 
As  its  name  indicates,  it  consists  in  the  suppression, 
in  the  asylums,  of  guards  and  enclosing  walls.  Prac- 
ticed only  in  Scotland,  the  country  par  excellence 
of  reforms  and  innovations  of  this  kind,  it  is  still  far 
from  having  had  its  last  word. 

Non-restraint  proposed  in  England  by  ConoUy 
and  Gardiner  Hill,  and  imported  into  France  by 
Morel  and  Magnan,  consists  in  the  complete  sup- 
pression among  the  insane  of  means  of  physical  re- 
straint, and  especially  of  the  camisole.  Long  main- 
tained as  an  absolute  princijjle  by  its  partisans,  this 
system  is  tending  to  gradually  lose  its  ground,  even 
in  the  country  of  its  origin  (V.  Parant,  1890). 
Circumstances  exist,  in  fact,  such  as  too  violent  ag- 
itation, propensities  to  voluntary  mutilation,  suicide, 
homicide,  etc.,  when  it  becomes  necessary  to  restrain 
the  patient.  The  camisole,  used  skilfully,  without 
roughness,   and    in    such   a   way   as    not  to    at    all 


HYGIENE.  569 

embarrass  the  respiration,  is  the  only  procedure  to 
which  we  should  have  recourse. 

The  physician,  moreover,  and  he  alone,  should  be 
the  judge  as  to  the  need  of  the  use  of  the  camisole 
and  the  length  of  time  it  should  be  employed.  In 
no  case  should  it  be  left  to  the  attendants  to  decide, 
since  such  a  course  necessarily  tends  to  cause  abuse. 

When  it  is  not  absolutely  necessary  to  confine  the 
patient's  arms,  but  only  his  hands,  as,  for  example, 
in  cases  of  extreme  tendency  to  onanism  or  destruc- 
tion of  clothing,  the  camisole  may  be  replaced  by  a 
muff  of  leather  or  canvas  which  confines  the  hands 
to  the  level  of  the  belt. 

It  is  in  only  very  exceptional  cases,  and  when  ab- 
solutely necessary,  that  we  may,  for  a  short  time 
only,  have  to  fasten  the  limbs  of  a  patient  to  the  bed, 
by  means  of  specially  designed  straps,  well  padded, 
and  moderately  tightened  around  the  ankle. 

2. — Special  Agents. 
A. — Hygienic. 

The  hygienic  treatment  of  insanity  includes  the 
usual  sanitary  regulations  in  regard  to  clothing, 
habitation,  food,  sleep,  etc. 

The  clothing  of  the  insane  calls  for  no  special 
remark  except  that  it  ought  to  be  ample  and  free, 
and  especially  that  it  should  not  be  too  tight  around 
the  neck,  on  account  of  the  possible  congestive 
tendency  of  many  of   the   patients.     The  dwelling, 

MENT.  MED.~3(i. 


570  TKEATMEXT  OF  Ilf SANITY. 

beiug  usually  an  establishment  for  the  care  of  the 
insane,  or  at  least,  as  we  have  seen,  a  house  arranged 
for  this  purpose,  there  is  no  need  here  to  point  out 
the  rules  that  ought  to  guide  its  construction  and 
management ;  it  need  only  be  said  that  the  patients' 
rooms  should  be  wholesome,  well  secured,  well  ven- 
tilated and,  as  far  as  possible,  on  the  ground  floor. 
The  food  should  be  wholesome,  tonic  and  nourishing ; 
excitants,  wine  and  alcoholic  liquors  in  particular, 
without  being  absolutely  forbidden,  ought  to  be  used 
only  in  moderation.  Milk,  eggs,  soup,  white  meats 
and  fresh  vegetables  should  form  the  general  basis 
of  the  nourishment.  For  general  paralytics,  espe- 
cially in  their  later  stages,  the  food  should  be  given 
cut  small,  and  tlie  meat  hashed,  to  avoid  asphyxia. 
Finally,  the  hours  of  meals  should  be  as  regular  as 
possible  with  the  insane.  As  to  tbeir  sleeping  quar- 
ters there  is  nothing  special  to  note,  except  with  un- 
tidy patients  who  need  special  arrangements  for 
cleanliness. 

The  best  bed  for  untidy  patients  is  an  iron  bed- 
stead with  straight  sides,  but  with  the  bottom  formed 
by  a  double  incliued  plane,  sloping  toward  the  centre, 
which  is  perforated,  and  thus  permits  liquids  to  pass 
into  a  vessel  underneath.  The  bed  is  filled  with  sea 
wrack  or  dry  turf  (Cuylits)  which  is  covered  with 
a  cloth.  Changing  the  cloth  each  day  and  remov- 
ing every  morning  that  part  of  the  sea-weed  or  turf 
that  is  soiled,  we  have  a  clean  and  perfectly  dry  bed. 
Instead  of  this  bed  we    may  use   an  ordinary  bed 


MORAL  TEEATMENT.  571 

with,  in  place  of  one  large  mattress,  three  small 
ones.  The  one  in  the  middle  may  be  filled  with  sea- 
weed, straw,  oat  chaff,  etc.,  and  is  intended  to  be 
soiled  and  replaced  each  day.  Above  these,  on  the 
tick  or  mattress  a  waterproof  rubber  cloth  may  be 
used.  Air  or  water  mattresses  may  also  be  employed. 
The  best  arrangement,  however,  when  a  proper 
bed  for  untidy  patients  cannot  be  had,  is  made 
by  using  a  large  and  thick  rubber  blanket  made 
with  a  tunnel-like  tube  in  its  centre,  which,  passing 
through  the  mattress,  carries  the  drainage  into 
a  vessel  underneath.  With  this  practical  ar- 
rangement any  bed  whatever  may  be  utilized,  and 
I  have  always  employed  it  for  untidy  patients  w^hom 
I  have  had  to  treat  in  private  houses. 

In  these  ways  we  contrive  to  secure  a  wholesome 
and  dry  bed  for  the  patient,  and  to  prevent,  to  a 
considerable  extent,  with  the  use  of  the  usual  means 
of  cleanliness,  the  occurrence  of  bedsores  and  sloughs. 

B. — Psychic  Agcneies. 

Under  this  head  we  take  up  the  subjects  of  moral 
treatment  and  suggestion,  which  form  the  two  prin- 
cipal elements  of  the  psychic  treatment  of  the  insane. 

3Ioral  Treatment. — Moral  treatment,  together 
with  isolation,  is  one  of  the  most  important  agencies 
in  the  cure  of  insanity.  Its  direction  should  belong 
to  the  physician  alone,  by  virtue  of  his  situation,  his 
profession,  his  authority,  and  his  character.     Moral 


572  TEEATMENT  OF  rNSANTTY. 

direction  therefore  consists  essentially  in  the  psychic 
influence  exercised  on  the  patient  for  the  purpose  of 
cure  by  the  physician  himself  or  under  his  direction. 
All  mental  disorders  do  not  act  in  the  same  manner  in 
this  regard,  and  some  are  particularly  susceptible  of 
being  influenced  by  this  kind  of  treatment.  Melan- 
cholia is  one  of  these. 

The  medical  action  is  exercised  in  very  different 
ways  according  to  the  case,  and  it  demands  a  tact, 
skill,  and  knowledge,  that  is  only  acquired  after  long- 
practice.  It  may  be  said,  without  exaggeration, 
that  the  physician,  by  his  mere  presence  and  the 
influence  which  he  exercises  when  with  the  patient, 
is  a  potent  agency  for  the  cure.  It  is  only  neces- 
sary to  see  in  asylums  with  what  impatience  the 
doctor's  visit  is  expected,  what  good  impressions  his 
encouragement  and  advice  produce  in  some  melan- 
choliacs,  to  recognize  his  influence.  As  a  general 
rule  the  physician  ought  to  show  the  greatest  polite- 
ness to  and  symi3athy  for  his  patients.  However 
absorbed  they  may  be  in  their  delusions,  the  insane 
are  always  sensible  of  kindnesses  and  marks  of  inter- 
est in  them,  and  this  is  one  of  the  best  means  of 
gaining  their  good  will  and  gaining  control  of  them. 
It  is  needful  to  listen  to  them,  treat  them  with 
authority,  although  with  kindness ;  to  make  them  feel 
that  in  their  physician  they  have  an  adviser  and  a 
moral  support;  not  to  openly  ridicule  their  ideas, 
even  the  most  unreasonable  ones,  nor  to  contradict 
too  flatly ;  to  take  care,  nevertheless,  not  to  ajjpruve 


MOKAL  TR-RATMENt. 


373 


of  them  or  to  consider  their  dehisions  as  the  expression 
of  the  truth ;  to  direct  and  regulate  with  care  and 
judgment  the  interviews  with  relatives  and  friends, 
the  correspondence,  the  occupation,  the  diversions 
(manual  and  mental  employment,  promenades,  paint- 
ing, designing,  music,  singing,  entertainments,  relig- 
ious exercises,  etc.,  etc.);  to  encourage  them  when 
they  begin  to  doubt  their  delusions  and  help  them  to 
gradually  appreciate  the  reality ;  and  in  certain  cases, 
where  their  obstinacy,  indocility,  and  persistence  in 
their  fixed  ideas  or  morbid  acts  necessitate  it,  to 
change  the  attitude,  to  act  with  authority,  be  severe, 
and  use  intimidation,  never  however  going  so  far  as 
to  use  violence.  All  these  means  are  excellent 
and  have  a  great  value  in  the  hands  of  experienced 
physicians ;  but  they  are  two-edged  weapons  that 
should  be  employed  only  wittingly  and  with  prudence. 
As  is  well  known  Leuret  has  made  argument  and 
intimidation  the  basis  of  a  systematic  treatment, 
which  he  calls  moral  treatment.  This  consists  prac- 
tically in  convincing  the  lunatic  of  his  errors  either 
willingly  or  by  force.  As  the  one  principle  of  treat- 
ment this  system  is  evidently  not  acceptable  and  is, 
moreover,  hardly  capable  of  producing  satisfactory 
results.  The  patients  are  shocked  and  humiliated, 
they  are  embittered  by  these  methods,  they  are  com- 
pelled to  admit  their  insanity  without  being  con- 
vinced ;  they  are,  in  short,  placed  in  the  situation  of 
those  who  in  former  times  were  forced  by  torture  to 
confess  crimes  of  which  they  were  innocent.     It   is 


574  TEEATMEISTT  OF  IN'SANTTY. 

not  necessary  to  be  acquainted  with  the  insane  to 
know  that  their  errors  are  not  such  as  can  be  up- 
rooted by  force,  and  that  it  is  needful  to  leave  them 
to  wear  away  and  disappear  spontaneously. 

Suggestion. — Therapeutic  suggestion  maybe  prac- 
ticed, as  we  are  aware,  in  two  ways;  cither  during 
the  waking  state  or  in  the  hypnotic  condition.  The 
first  of  these  is  as  old  as  medicine  itself,  and  numer- 
ous remedies  owe  to  it,  either  wholly  or  in  part,  their 
virtues.  (See  Dr.  Hack  Tuke's  "Influence  of  the 
Mind  upon  tlie  Body.")  As  Doutrebente  well  re- 
marked at  the  last  International  Congress  of  Mental 
Medicine,  the  moral  effect  of  the  physician  on  the 
insane  is  especially  a  suggestive  action,  a  suggestion 
in  the  waking  state.  As  to  hypnotic  suggestion, 
although  previously  known,  it  has  only  within  the 
past  few  years  been  studied  experimentally  and  ap- 
plied to  the  treatment  of  disease. 

In  the  domain  of  neuro-patliology  therapeutic 
suggestion  has  already  produced  undeniable  results. 
It  is  effective  especially  in  dynamic  disorders, 
or  those  without  recognized  anatomical  lesions  of  the 
nervous  system,  chiefly  in  neuralgias,  hystero-epileptic 
attacks,  paralyses,  contractures,  hysterical  ana39- 
thesias  and  vomiting,  rebellious  ceplialalgias,  chorea, 
etc. 

Its  action  on  the  psychoses  is  much  more  question- 
able. A  priori  it  is  logical  to  think  that  an  agent 
of  this  kind,  capable   of  modifying  the  ideas,  the 


STJGGESTIOIJT.  575 

feelings  and  even  the  personality  of  an  individual, 
might  be  able  to  construct  what  it  has  undone,  that 
is,  to  call  back  the  ideas  to  their  normal  condition, 
and  the  feelings  and  personality  to  the  one  who  has 
lost  them.  Unfortunately  experience  has  given  only 
a  negative  answer  up  to  the  present,  at  least  in  the 
majority  of  cases. 

M.  Auguste  Voisin  was  the  first  who  attempted 
the  application  of  hypnotic  suggestion  to  the  treat- 
ment of  mental  disorders.  Since  then  a  great  many 
authors,  Frencli  and  foreign,  have  reported  the  re- 
sults of  their  own  experience  in  this  regard.  I  will 
cite  among  them:  Benedikt  (of  Vienna),  Forel  (of 
Zurich),  Ladame  (of  Geneva),  Castelli  and  Lom- 
broso,  Beruheim,  Bremaud,  Fontan  and  Segard, 
Peyronnet,  Ventra,  Amadei,  Dumontpallier,  Ober- 
steiner,  Vizioli,  Bottez  and  Mall,  Herter,  Berillon, 
Algeri,  Percy  Smith,  and  A.  T.  Myers,  and 
lastly  Seppili,  whose  recent  remarkable  study 
is,  at  the  present,  the  best  we  have  on  the  subject. 
(Archivio  itaUano,  Sept.,  1890).  It  appears  from 
the  whole  of  these  memoirs  that, — as  Bernheim  has 
shown,  and  as  I  pointed  out  veiy  clearly  in  1884, 
in  reply  to  M.  Auguste  Voisin  (Ass.  for  Advancem. 
of  Sciences,  meeting  at  Blois), — the  insane  are  most 
frequently  refractory  to  hypnotism,  and  only  hys- 
terical, epileptic,  dipsomaniac,  and  obsessed  cases 
seem  to  be  susceptible  to  hypnosis  and  benefited  by 
suggestion.  The  following  are  the  very  judicious 
conclusions  of  Seppili's  paper: 


576  TREATMENT  OF  INSAISTTTT. 

(1)  Hypnotic  suggestion  cannot  be  employed  as 
a  means  of  treatment  in  mental  diseases,  on  account 
of  the  difficulty  of  hypnotizing  the  insane. 

(2)  The  best  results  of  therapeutic  hypnotic  sug- 
gestion have  been  obtained  so  far  in  the  psychoses 
dependent  on  hysteria  and  dipsomania. 

(3)  Hy]3notic  suggestion  may  be  employed  when 
the  patient  takes  to  it  kindly  and  is  profited  by  it. 
The  practitioner  should  employ  it  only  with  great 
caution  and  note  any  injurious  effects  which,  in  cer- 
tain cases,  may  be  produced. 

(4)  Therapeutic  suggestion  in  the  waking  state  is 
the  most  useful  and  efficacious  agency  in  the  treat- 
ment of  insanity,  and  to  it  alone  are  due  the  salu- 
tary effects  of  the  asylum,  which  has  a  really  sug- 
gestive character. 

(5)  In  cases  of  melancholia  without  delusions, 
fixed  ideas,  alcoholism  and  the  milder  forms  of 
stupor,  repeated  methodical  suggestion  in  the  waking 
state,  employed  to  combat  the  morbid  phenomena, 
may  be  very  useful, 

(6)  In  the  chronic  forms  of  insanity,  and  in  paral- 
ysis, suggestion  has  never  afforded  any  good  results. 

Physical  Agents. 

The  principal  physical  agents  in  the  treatment  of 
insanity  are :  liydrotherapy,  electrotherapy,  and  mas- 
BOtherapy. 


HTBROTHEEAPY.  577 

Hydrotherapy. — Hydrotherapy,  readily  em- 
ployed in  mental  medicine,  has,  nevertheless,  been 
thus  far  hardly  utilized  except  in  an  altogether 
empirical  fashion.  In  tolerably  complete  medical 
studies  of  the  subject,  I  can  only  cite  the  interesting 
general  review  by  my  friend  Jules  Morel  of  Gand 
{Bulletin  de  la  Son.  de  Med.  MenfMe  de  Belgique^ 
Dec,  1889),  and  the  chapter  on  hydrotherapy  of 
Kovalewsky's  recently  translated  work  on  the 
treatment  of  mental  and  nervous  diseases. 

The  hydrotherapeutic  methods  utilized  in  psychi- 
atry are  the  same  as  those  ordinaril}'^  employed.  I 
will  state  here  those  that  are  best  known,  such  as  are 
indicated  by  my  distinguished  confrere  and  friend. 
Dr.  Delmas  (of  Bordeaux)  in  his  excellent  Manuel 
d^hydrotherapie.  ^ 

The  apparatuses,  formulas,  and  hydrotherapeutic 
methods  vary  according  as  they  involve  the  appli- 
cation of  heat  or  of  cold, 

1. — Among  the  caloric  methods  I  will  mention  the 
dry  pack.  The  patient  is  laid  naked  on  a  mattress 
and  is  covered  with  one  or  two  blankets  tightly  ap- 
plied and  kept  thus  by  an  outer  cloth,  with  the 
purpose  of  provoking  perspiration. 

The  icet  pack.  Two  woolen  blankets  are  laid 
over  an  ordinary  bed,  and  over  these  is  laid  a  cloth 
previously  dipped  in  water  of  from  8°  to  12°  C. 
(46.4*^  to  53.6*^  F.)  and  then  thoroughly  wrung  out. 
The  patient  is  placed  naked  on  this  cloth,  which  is 
then  wrapped  around  him  with   folds  inserted   be- 


578 


TREATMENT  OF  INSAISTITY. 


tween  the  thighs  and  between  the  arms  and  body  so 
that  the  whole  surface  of  the  skin  is  in  contact  with 
the  moist  cloth.  Then  the  blankets  are  wrapped 
around  the  patient  and  securely  fastened.  If  a  tonic 
sedative  effect  is  wanted  the  patient  should  remain 
enveloped  from  ten  to  twenty  minutes ;  but  it  should 
be  continued  for  from  an  hour  and  a  half  to  three 
hours,  as  with  the  dry  pack,  if  a  sudorific  action  is 
sought.  Other  methods  of  inducing  perspiration 
are  used,  such  as  stoves,  both  of  the  ordinary  kind 
or  those  special  for  this  purpose,  hot  air  baths,  fumi- 
gations, and  embrocations.  The  name  of  Russian 
bath  is  given  to  a  sudation  followed  by  cold  im- 
mersion, and  Turkish  bath  to  the  same  succeeded  by 
massage.  Foreign  alienists,  especially  the  English 
and  Americans,  praise  these  methods  very  highly, 
and  constantly  make  use  of  them. 

I  will  mention  further,  as  methods  of  employing 
heat,  the  warm  bath,  the  piscina,  the  vapor  douche, 
the  warm  douche,  the  Scotch  douche  and  the  altern- 
ating douche.  The  Scotch  douche  is  a  warm  douche 
followed  suddenly  by  a  cold  one.  The  alternating 
douche  is  the  Scotch  douche  repeated  many  times  in 
succession. 

2. — The  application  of  cold  is  also  made  by  numer- 
ous methods,  among  which  ma}' be  mentioned,  ^:)ar^/a/ 
or  general  envelopment.  Partial  envelopment  bears 
the  name  of  cincture.,  from  the  region  to  which  it  is 
most  frequently  applied.  It  is  applied  by  means  of 
a  towel  soaked  in  cold  water  and  wrung  out  more  or 


HTDEOTHERAPT. 


579 


less  completely,  surrounding  the  body  and  covered 
with  dry  linen  or  water-proof  so  as  to  produce  a 
local  vapor  bath.  The  wet  cloth  serves  for  a  general 
envelopment.  Dipped  into  cold  water  and  partially 
wrung  out,  it  envelops  the  whole  body,  and  then 
energetic  friction  with  the  flat  of  the  hand  is  employed. 

In  hnmersion  the  body  is  plunged  into  cold  water. 
The  immersion  is  total  (bath  tub,  tank,  swimming 
basin)  or  partial  (half  bath,  sitz  bath,  arm,  hand 
and  foot  baths).  In  the  affusion  bath,  the  body 
plunged  in  water  of  a  bath  tub,  of  moderate  temper 
ature,  receives  from  the  sprinkler  of  a  watering-pot 
a  shower  of  a  more  or  less  lowered  temperature. 

The  projection  of  cold  water  on  the  body  con- 
stitutes the  douche.  This  is  general  or  local.  The 
general  douche  is  called,  according  to  its  form, 
shower,  circle,  jet,  sheet,  needle,  palette,  lance, 
column,  direct,  and  broken.  Local  douches  in  their 
turn,  according  to  the  case,  receive  the  names  of 
hepatic,  splenic,  epigastric,  hypogastric,  ascending, 
vaginal,  uterine,  lumbar,  anal,  etc.,  douches, 

Hji'drotherapy,  in  its  principal  therapeutic  effects, 
is  sedative,  stimulant  or  tonic.  In  a  general  way 
the  sedative  effects  follow  the  use  of  warm  and  the 
stimulating  or  tonic  effects  the  use  of  cold  water. 
This  is,  nevertheless,  not  an  absolute  rule,  and 
the  duration  as  well  as  the  mode  of  the  application 
act,  as  well  as  the  temperature,  on  the  final  result. 
As  a  rule  the  best  method  is  that  using  moderately 
cool    or  temperate  douches   20°   to  30°  C.    (==  68° 


580  TREATMENT  OF  INSAKITY. 

to  86°  F.)  as  a  beginning  of  the  treatment,  taking 
due  note  of  the  season,  the  temperature  of  the  atmos- 
phere, and  the  condition  at  the  time.  As  regards 
duration  it  ought  not  to  exceed  ten  seconds  at  the 
beginning,  with  water  at  12°  C.  (=  53.6°  F.), 
and  half  a  minute  at  the  maximum,  if  the  water  is 
raised  to  a  temperature  of  18°  to  24°  C.  (=  64.4° 
to  75.2°  F.)   (Delmas). 

There  is  no  need  here  to  describe  the  apparatuses 
of  hydrotherapy,  every  one  is  now  acquainted  with 
them.  I  will  limit  myself  to  saying  that  institutions 
for  the  insane  ought  to  possess  a  hydrotherapeutic 
outfit  suited  to  the  varying  needs  of  practice.  For 
the  treatment  of  patients  at  home,  we  maj  use  the 
so-called  shower  bath.  I  jDrefer  a  simple  copper  ir- 
rigating pump,  which,  placed  in  anj^kindof  a  vessel, 
suffices  at  all  times  and  places,  for  the  administra- 
tion of  warm,  cold,   8cotch,  and  alternating  douches. 

T  need  not  pass  in  review  here  all  the  mental  dis- 
orders in  which  hj^drotherapy  is  useful,  but  will  con- 
fine m3^self  to  stating  the  chief  ones. 

Neurasthenia. — In  cases  of  nervous  excitement, 
temperate  plunge  baths,  affusions,  wet  pack,  douches 
of  slight  force,  moderately  cool,  and  of  short  du- 
ration, general  friction  with  a  wet  cloth,  lotions, 
etc.  In  cases  with  symj^toms  of  exhaustion  we 
should  not  at  once  have  recourse  to  the  cold  douche 
but  should  begin  with  a  mixed  douche.  Later  when 
the  patient  is  acclimated  to  hydrotherapy,  use  ex- 


HTDEOTHERAPT.  581 

citant  applicationB,  such  as  shower  baths,  and  short 
forcible  cold  jets,  brief  immersions  in  cool  water, 
frictions  with  wrung  out  wet  cloth,  etc.,  etc.  K 
cerebral  symptoms  break  out  and  there  is  hyper- 
excitement  of  the  brain,  cold  lotions  with  sponges  or 
cold  compresses  applied  to  the  head  and  frequently 
changed,  moderately  cool  showerings  with  slight 
force,  warm  affusions  when  pain  is  produced  by 
cold  ones.  If,  on  the  contrary,  there  is  cerebral 
adynamia,  the  local  treatment  should  be  excitant, 
but  the  hydriatic  applications  should  be  closely 
watched  and  should  be  mild,  short  and  progress- 
ively cooled  (Beni-Barde). 

3Ielancholia.  — The  hydrotherapeutic  treatment 
is  very  simple.  It  should  first  of  all  be  tonic  and 
reconstituant.  Douches  of  moderate  pressure,  short, 
general  and  cool.  Proceed  with  judgment  using 
first  water  of  82°  to  85.6°(F.)  according  to  the  sea- 
son and  gradually  reduce  the  temperature.  A  re- 
vulsive action  may  be  needed  in  the  course  of  the 
treatment;  it  can  be  had  by  the  use  of  shower 
baths.  The  tonic  action  is  increased  by  the  use  of 
the  plunge  bath,  when  it  is  not  contra-indicated. 
If  a  tonic  and  a  still  more  energetic  disturbing 
action  are  both  wanted  at  the  same  time,  this 
end  is  best  attained  by  the  Scotch  douche.  If 
instead  of  a  depressed,  we  have  to  treat  an  excited 
or  anxious  form  of  melancholia,  general  warm  baths 
with  affusions  to  the  head,  or  a  warm  shower  bath, 
should  be  ordered. 


582  TREATMENT  OF  INSANITY. 

Mania. — Here  the  warm  bath  of  from  82°to  93° 
F.  is  the  hydriatic  treatment  par  excellence.  This 
may  be  prolonged  sometimes  for  several  hours,  care 
being  taken  to  keep  cold  compresses  applied  to  the 
head  or  the  cold  cap  of  Leiter  or  Winternitz.  Schtile 
also  uses  in  subacute  mania  cold  baths  of  from  59° 
to  68°  F.  lasting  eight  to  ten  minutes,  together 
with  the  application  of  ice  to  the  head  followed  by 
friction  and  rest  in  bed.  Briand  has  also  employed 
cold  baths  as  antithermics  in  acute  delirium.  Svetlin 
recommends  the  use  of  prolonged  packs  with  towels 
dijjped  in  water  of  60°  to  68°  F.,  to  combat  excite- 
ment :  the  calmative  and  hyjjnotic  effects,  he  claims, 
will  never  fail.  Kroepelin,  Krafft-Ebing,  Schille, 
Arndt,  Salgo,  have  had  good  results  with  this 
method,  especially  in  feeble  patients.  The  Russian 
and  Turkish  baths  also  have  excellent  effects,  ac- 
cording to  certain  foreign  authors,  in  mania  as  well 
as  in  other  forms  of  insanity. 

General  Paralysis. — *'In  this  disease,"  says 
Delmas,  "  hj'^drotherapeutic  measures  should  be  em- 
ployed only  with  great  caution.  Extreme  temper- 
atures should  be  avoided,  also  douches  with  great 
pressure  and  especially  of  long  duration.  When  the 
disorder  assumes  the  congestive  form  and  the  alter- 
ations are  yet  but  slightly  advanced  there  is  yet  hope 
of  retarding  the  final  explosion.  Aside  from  these 
cases,  however,  the  physician  should  abstain  from 
all  promises,  and  generally  consent  to  use  the  treat- 


ELECTROTHERAPY.  583 

ment  only  with  the  fullest  reservations."  These 
wise  words  of  a  specialist  are  profoundly  true.  I 
will,  for  my  own  part,  go  still  farther,  and  declare 
that,  after  numerous  experiences,  apart  from  simple 
bathing,  properly  so-called,  hydrotherapy  in  all  its 
forms,  is  useless  and  even  dangerous  in  progressive 
general  paralysis. 

Electrotherapy. — Electrotherapy,  that  potent 
method  of  treatment,  hitherto  too  much  neglected, 
seems  destined  to  play  a  very  important  part  in  the 
therapeutics  of  insanity.  We  sum  up  here  some  of 
its  indications  according  to  the  memoirs  of  Erb, 
Kovalewsky  and  Morel,  and,  according  to  the 
advice  of  our  excellent  friend.  Professor  Bergonie. 

We  use  in  psychiatry  the  usual  electrotherapeutic 
procedures :  the  constant  current  or  galvanization, 
the  interrupted  current  or  faradization,  and  static 
electricity  or  franklinization. 

Constant  Current  or  Galvanization. — The  con- 
stant current  for  medical  applications  by  means  of 
elements  of  piles  connected  in  series.  It  is  indis- 
pensable to  measure  the  amount  of  the  current 
utilized.  This  is  done  by  means  of  galvanometers 
graduated  in  milliamperes  (the  milliampere  being 
the  unit  of  quantity  of  current  emploj^ed  in  med- 
icine) .  For  therapeutic  purposes  of  the  constant  cur- 
rent, the  battery  should  furnish  at  least  a  current 
of  15  or  20  milliamperes.     The  current  is  applied  by 


584  TEEATMENT  OF  INSANITY. 

means  of  electrodes,  the  form  and  surface  of  which 
vary  with  the  applications  intended.  The  electrode 
connected  with  the  positive  pole  of  the  battery  is 
sometimes  called  the  anode^  that  connected  with  the 
negative  pole  is  called  the  cathode.  The  intensity 
of  the  current  at  any  electrode  is  the  quotient  of  the 
intensity  of  the  current  by  the  surface  of  the  elec- 
trode. ^Tien  the  density  of  the  current  is  very  fee- 
ble, that  is,  when  the  surface  of  the  electrode  is  very 
great,  the  action  of  that  electrode  is  very  slight, 
and  it  receives  the  name  of  the  indifferent  or  inact- 
ive electrode.  When,  on  the  contrary,  the  surface 
is  small,  the  current  density  at  that  electrode  is 
great  and  it  takes  the  name  of  the  active  electrode. 
Sometnnes  the  indifferent  electrode  may  be  formed 
by  all  the  water  of  an  ordinary  bath,  the  active 
electrode  being  applied  on  some  non-immersed  part 
of  the  body  of  greater  or  less  extent.  This  is  what 
is  called  the  galvanic  bath  when  the  constant  current 
is  employed,  and  the  faradic  bath  when  the  faradic 
current  is  used.  The  human  body  interposes  a 
greater  or  less  resistance  to  the  passage  of  the  cur- 
rent, the  greater  part  of  which  is  due  to  the  skin. 
The  unit  of  resistance  bears  the  name  of  ohm.  The 
greater  or  less  degree  of  dryness  of  the  skin  has  a 
great  influence  on  the  resistance.  In  order  to  dimin- 
ish it  as  much  as  possible  the  part  on  which  the 
electrode  is  placed  should  be  moistened  with  warm 
water,  or  still  better  the  fatty  matter  should  be 
removed   by   friction    with   alcohol.     A   rheoatat  is 


ELECTROTnERAPY.  585 

an  instrument  that  introduces  progressively  increas- 
ing resistances  into  the  circuit.  It  will  be  seen  that 
in  this  way  we  can  vary  the  intensity  of  a  current 
from  the  same  number  of  elements,  since  the  in- 
tensity of  a  current  is  inversely  proportional  to  the 
resistance  of  the  circuit  it  traverses.  A  commutator 
or  current-reverser  is  an  apparatus  that  serves  to 
change  the  direction  of  a  current  in  the  body,  by 
which  manoeuver  the  positive  becomes  the  negative 
pole,  and  vice  versa.  The  collector  of  elements  (or 
switch  board)  is  the  apparatus  for  introducing  into 
the  circuit  or  cutting  out  the  different  elements  of 
the  battery.  In  some  cases  an  interrupter  is  added 
by  which  the  current  is  broken  and  set  in  action 
again. 

The  constant  current  is  used  for  the  electrization 
of  the  head,  the  spinal  cord,  the  great  sympathetic 
and  the  peripheral  nerves. 

Cerebral  galvanization  has  a  sedative  action  on 
the  nervous  system,  and  is  therefore  indicated  in 
cases  of  motor  or  intellectual  excitement.  It  is  very 
useful  in  neurasthenia  (Hughes,  Althaus),  epilepsy, 
the  prenionitory  period  of  general  paralysis  (Arndt, 
Hitzig,  Schiile),  lypemania,  mania  (Schiile,  Tigges, 
Von  Heyden,  Wiglesworth,  etc.)  It  should  be 
commenced  with  a  current  intensity  of  zero,  very 
slowly  increased.  Ordinarily  the  electrodes  are 
applied  longitudinally,  and  they  are  applied  obliquelj'- 
only  in  very  exceptional  cases.  The  patient  should 
not  see  sparks  or  wink  if  the  apparatus  is  properly 

Mext.  Med.— 37. 


586  TREATMEl'^  OF  INSANITY. 

managed.     The  average  duration  of  each  seance  \% 
from  five  to  ten  minutes. 

Sjyinal galvanization  is  designed  to  pass  the  current 
through  the  spinal  cord.  It  may  be  followed  by 
excellent  effects  in  medullary  disorders  and  in  myelas- 
thenia,  but  it  is  scarcely  used  in  mental  diseases, 
except  occasionally  in  psychoses  with  excitement 
(Arndt  and  Newth).  A  rather  strong  current, 
fifteen  to  twenty  milliamperes,  for  ten  to  fifteen 
minutes,  is  permissible.  In  functional  disorders  .the 
length  of  the  sittings  ought  to  be  less  than  in 
organic  affections. 

Galvanization  of  the  sympathetic  has  been  so  far 
insutiiciently  studied  and  has  been  much  criticized. 
It  seems,  nevertheless,  to  have  before  it  a  certain 
future,  since  we  can  act  on  the  caJiber  of  the  blood- 
vessels by  way  of  the  sympathetic  and  regulate  the 
circulation  toward  the  various  organs, — notably 
toward  the  brain.  As  yet  we  know  only  the  action 
of  galvanization  on  the  superior  cervical  ganglion  as 
it  is  the  one  most  accessible  to  the  current.  When 
speaking  therefore  of  galvanization  of  the  sympa- 
thetic, it  is  therefore  understood  that  we  refer  to  this 
ganglion  only.  'J'o  apply  the  current  the  active 
electrode  is  usually  placed  in  the  auriculo-maxillary 
fossa,  and  the  indifferent  on  the  chest,  the  occiput, 
or  the  vertebral  column.  If  the  galvanization  is 
made  on  both  sides  simultaneously  a  douV>le  electrode 
is  employed.  The  current,  feeble  at  first,  is  gradu- 
allv  increased,  and    for   this  reason    a   rheostat    is 


ELECTROTHERAPY.  587 

convenient  in  the  circuit.  The  action  of  the  diiferent 
poles  is  not  well  determined  as  yet,  though  clinical 
observations  show  that  the  application  of  the  positive 
pole  to  the  ganglion  rapidly  causes  redness  of  the 
face,  flow  of  blood  to  the  head  and  a  feeling  of  weight 
and  slight  vertigo.  The  negative  pole,  on  the  other 
hand,  causes  pallor  of  the  face  and  sometimes  a 
sensation  of  emptiness  in  the  head  and  vertigo. 
These  facts  sufficiently  indicate  the  choice  of  poles 
in  the  different  disorders.  Thus  we  should  employ, 
subject  to  later  change  if  necessary,  the  positive  pole 
in  neurasthenia,  Basedow's  disease,  lypemania,  hypo- 
chondria, and  dementia,  and  the  negative  pole  in 
general  paralysis. 

Galvanization  of  the  peripheral  nerves  is  hardly 
utilized  in  mental  medicine.  Central  galvanization 
and  general  galvanization  as  recommended  by  Beard, 
are  of  limited  application  and  rather  difficult. 

Intermpted.  or  Induced  Onrrent  or  Faradiza- 
tion.— This  current  is  produced  by  means  of  a 
Rumkhorif  coil  specially  constructed  for  medical 
use.  We  recommend  a  sliding  apparatus  giving  as 
'  regular  a  current  as  possible,  on  which  we  may  use 
either  a  fine  or  a  coarse  wire  bobbin.  The  same 
electrodes  are  employed  as  in  galvanization. 

Cerebral  or  spinal  faradization  are  hardly  used  at 
the  present  time  on  account  of  the  uncertainty  as  to 
their  action,  and  peripheral  faradization  is  the 
method   almost   always  employed.     This  acts    not 


588  TREATMENT  OF  INSANITY. 

only  locally,  but  in  a  reflex  way  on  the  nervous 
centres.  On  account  of  this  reflex  action  it  has  been 
recommended  by  Benedikt  and  Arndt  in  certain 
psychoses,  notably  in  cases  of  psychic  depression 
and  melancholic  stupor.  The  results  obtained  seem 
very  satisfactory.  There  are  two  kinds  of  faradi- 
zation:  the  deep  and  the  superficial.  Superficial 
faradization  afl:'ects  particularly  the  nerve  endings 
in  the  skin,  consequently  the  sensory  nerves.  It  is 
applied  with  a  dry  electrode  or  a  metallic  brush. 
In  order  to  make  the  current  penetrate  more  deeply, 
into  the  muscular  structure,  it  is  necessary  that  the 
electrode  and  the  part  of  the  body  over  which  it  is 
passed  should  be  sufl^iciently  moistened. 

Static  Electricity  or  Franklinizatio7i. — Static 
electricity  is  produced  by  friction  or  influence 
machines.  The  ones  most  used  in  France  are  those 
of  Carre,  Voss,  Vigouroux,  and  Wimshurst.  The 
necessary  accessories  are  an  isolated  stool  on  glass 
feet,  and  a  series  of  excitors  with  glass  or  ebonite 
handles.  The  patient  is  connected  by  a  conductor 
with  one  or  the  other  of  the  poles  of  the  machine. 
The  excitor,  held  in  the  physician's  hand  by  an  in- 
sulated handle,  is  connected  with  the  other  pole. 
Static  electricity  is  used  in  the  form  of  baths,  the 
electric  breeze,  the  aigrette,  the  electric  friction 
and  the  spark. 

To  give  the  static  electrical  bath,  the  patient  is 
made  to  sit  on  the  stool  connected  with  one  pole  of 


ELECTEOTHEEAPY. 


589 


the  machine  by  means  of  a  chain,  a  stem,  or  an  iso- 
lated wire  conductor.  The  machine  having  been  set 
in  action  the  patient  feels  in  all  unclothed  parts  of 
his  body  a  peculiar  sensation,  something  between 
that  of  a  current  of  air  and  that  of  cobwebs. 
Vigouroux  attributes  to  this  bath  a  feeble  sedative, 
chiefly  useful  in  the  neurosis. 

The  soufle  or  electric  breeze,  is  produced  in  the 
following  manner:  the  second  electrode,  in  the  form 
of  an  excitor  with  points,  is  brought  near  the  patient 
who  has  been  already  charged  with  electricity  by 
the  preceding  method.  There  then  pass  from  him 
electric  breezes  which  give  a  sensation  of  a  draft  or 
current  of  air  and  appear  in  the  darkness  like  lumin- 
ous radiations.  Vigouroux  attributes  to  them 
a  sedative  action  that  is  very  effective  against  the 
symptom  of  pain.  The  frotternent  or  electric  fric- 
tion, and  the  spark,  are  produced  by  a  spherical  or 
bulbous  excitor.  In  order  to  obtain  the  friction  it 
is  sufficient  to  pass  the  bulb  over  the  patients  body 
lightly.  If  the  part  to  be  electrized  is  bare,  the 
bulb  should  be  covered  with  silk,  without  which,  at 
the  moment  of  contact  the  body  becomes  a  con- 
ductor, and  no  sensation  is  produced.  To  draw  out 
the  sparks,  the  bulb,  uncovered  by  the  silk,  should 
be  held  a  short  distance  from  the  body. 

Franklinization,  especialh'-  recommended  by 
Charcot  and  Vigouroux,  gives  excellent  results  in 
certain  neuroses,  notablj'  in  hysteria,  Basedow's  dis- 
ease,   and    neurasthenia.      It    merits    to   become  of 


690  TEBATMENT  OF  INSANITY. 

common  use  even  in  the  psychoses,  especially  mel- 
ancholia and  hypochondria.  Its  use  is,  in  certain 
cases,  combined  with  that  of  galvanization  and 
faradization. 

Massotherapy. — Thus  far  massage  has  been  very 
little  utilized  in  mental  medicine,  at  least  in  France. 
It  has  been  more  employed  in  certain  foreign  coun- 
tries, associated  with  hydrotherapy  or  otherwise. 

I  will  say  that  the  manipulations  of  massage,  are 
the  efflearage^  and  the  rubbing,  frictions,  petrissage^ 
tapotement,  hachage,  and  passive  motion.  I  need 
not  describe  them  here. 

The  different  varieties  of  massage  find  their  spe- 
cial indications  in  the  various  forms  of  mental  disease. 

Frictions  and  effleurage^  associated  or  not  with 
cold  baths,  are  very  useful  in  stuporous  melancholia. 

A  general  massage,  under  the  form  of  petrissage^ 
is  indicated  in  the  various  neuroses,  hysterical, 
hypochondriacal,  and  neurasthenic  psychoses  (Kov- 
alewsky) . 

Other  Physical  Agents. — Other  physical  agents 
may  be  employed,  though  less  important  in  the  treat- 
ment, as  adjuvants.  Of  these  I  will  mention,  gym- 
nastics, equitation,  billiards,  canoeing,  swimming, 
and  especially  bicycling,  which,  from  its  availability 
and  its  freedom  from  danger,  is  suitable  for  many  of 
the  insane.  The  English,  always  first  in  these  mat- 
ters, have  already  noted  and  utilized  its  advantages 


OPEEATION8.  591 

(C.  Theodore  Ewart,  "  Cycling  for  the  Insane." 
Jour.  Ment.  Science^  1890).  I  have  also  had  re- 
course to  it  at  once  as  a  physical  stimulant  and  a 
psychic  derivative,  in  some  cases  of  neurasthenia, 
hypochondria  and  melancholia. 

Surgical  Agencies. 

Surgery  is  rarely  invoked  in  the  treatment  of  men- 
tal disorders.  Occasionally,  nevertheless,  its  inter- 
vention may  be  useful  if  not  necessary. 

Trephining.^  Cerebrotorny.,  Craniectomy. — Tre- 
phining has  been  formerly  tried,  it  seems,  for  insan- 
ity. Some  foreign  surgeons  seem  to  wish  to  revive 
this  method  at  the  present  time,  and  even  to  carry 
it  farther  than  before.  Thus  Batty  Tuke  and  Shaw 
(1889)  practiced  trephining  with  excision  of  the  dura 
in  general  paralysis,  with  the  vie^  of  relieving  the 
intra-cranial  pressure,  due  to  the  disease.  So  also 
Burkhardt,  Horsley,  and  Althaus  (1890)  have  car- 
ried out  a  series  of  operations  ( trephining,  excision 
of  parts  of  the  cortex,  ligatures  of  cerebral  arteries, 
extirpation  of  neoplasms)  with  the  view  of  curing 
or  ameliorating  certain  psychoses.  The  results  thus 
far,  however,  have  hardly  been  satisfactory. 

More  logical  and  assuredly  more  profitable,  is  the 
craniectomy  proposed  and  practiced  recently  by  Prof. 
Lannelongue  in  certain  cases  of  arrest  of  psychic  de- 
velopment from  primitive  synostosis  of  the  skull, 
with  the  idea  of  making  it  practicable  for  the  brain 


592  TKEATMENT  OF  INSAISTTY. 

to  reach  its  normal  expansion.  There  are,  as  yet,  too 
few  facts  to  enable  one  to  deduce  any  definite  con- 
clusion, but  this  operation  seems  destined  to  have  a 
certain  future. 

Hevulsion. — This  is  an  excellent  therapeutic 
method  in  mental  disorders  that  has  not  been  suf- 
ficiently resorted  to.  The  happy  results  of  sponta- 
neous suppurations  in  the  insane  enable  us,  indeed, 
to  conclude  a  2^riori,  as  to  efficaciousness  of  artificial 
revulsion,  and  numerous  clinical  facts  support  this 
opinion.  General  paralysis  itself,  refractory  we 
may  say  to  all  other  treatment,  can,  nevertheless,  be 
iufluenced  b}^  spontaneous  or  provoked  suppuration, 
and  not  infrequently  when  taken  in  its  beginning, 
the  disease  is  seen  to  give  wslj  temporarily  under 
the  influence  of  energetic  revulsive  measures. 

The  best  methT)d  of  revulsion  is  a  seton  in  the 
back  of  the  neck.  We  may  also  employ  permanent 
vesication,  punctate  cauterization  with  the  thermo- 
cautery, and  lastly  irritant  frictions;  but  these 
methods  are  generally  either  insufficient  or  too 
painful. 

Thyroidectomy.  Thyroid  Grafts. — It  is  well 
known  that  for  some  years  jDast  various  foreign 
surgeons,  following  the  lead  of  Reverdin  (of 
Geneva),  have  attempted  the  cure  of  goitre  by  ex- 
tirpation of  the  thyroid  gland,  or  thyroidectomy. 
After  this  operation   there  has  been  observed  in  a 


OPERATIONS.  593 

majority  of  the  cases,  a  particular  condition  of  de- 
generation, analogous  to  cretinism  (cachexia  strumi- 
priva,  or  operative  cretinism).  Hence  it  was 
naturally  deduced  that  the  suppression  of  the  thy- 
roid function  was  the  immediate  cause  of  cretinism 
and  pseudo-cretinism,  and  later  physiological  and 
experimental  researches  seem  to  confirm  this.  The 
cretinism  following  operations  is,  moreover,  avoided, 
as  we  are  aware  by  the  substitution  of  partial  for 
total  ablation  of  the  organ.  Such  being  the  case, 
it  is  naturally  asked  whether  the  artificial  re-estab- 
lishment of  the  thyroid  function  in  those  deprived 
of  it  could  not,  if  successful,  more  or  less  sensibly 
modify  their  condition.  Experiments  of  grafting 
the  thyroid  gland  of  a  sheep,  or  of  subcutaneous 
injections  of  thyroid  juice,  have  been  recently  made 
by  various  experimenters  (Horsley,  Lannelongue, 
Bettencourt-Rodrigues),  but  the  results  are  as  yet 
insufiicient  for  us  to  speak  confidently  in  regard  to 
the  method.* 

Together  with  thyroidectomy  I  will  mention  cas- 
tration and  clitoridectomy,  which  have  been  practiced 
abroad,  but  without  marked  success,  in  a  certain 
number  of  insane  females,  especially  in  cases  of 
hysterical  or  climacteric  insanity.  In  this  connec- 
tion, we  are  reminded  of  the  fact  that  in  sympa- 
thetic insanity,  and  particularly   in  that  connected 

*  Since  the  above  was  written  numerous  cases  have  been  reported 
in  medical  publications,  of  favorable  results  in  myxoedema  from 
injections  of  thyroid  extract,  and  from  thyroid  transplantation  or 
grafts. 


594  TREATMENT  OF  INSANITY.  ^ 

with  genito-uriuaiy  affections,  an  appropriate  sur- 
gical intervention  (ablation  of  tumor,  ^cauterization, 
application  of  a  pessary,  etc.),  has  often  caused  the 
disappearance  of  the  concomitant  psychic  symptoms. 

Blood- Letting.  Transfusion. — Bleeding,  for- 
merly much  resorted  to,  has  to-day,  as  we  are  aware, 
fallen  into  disuse,  and  if  it  was  carried  to  excess 
then,  we  may  say  that  it  is  now  too  little  employed. 
lii  certain  cases  when  the  congestive  condition  of 
the  brain  is  manifest,  there  should  be  no  hesi- 
tancy in  practicing  bleeding  or  of  applying  leeches 
either  to  the  head  or  the  arms. 

Transfusion  has  hardly  been  employed,  so  far  as 
1  know,  in  the  treatment  of  insanity.  The  operation 
is  too  complicated  and  the  indications  for  its  use  too 
restricted  for  it  to  be  of  advantage  in  any  but  very 
exceptional  conditions. 

IIy2^oderm/tc  Injections. — The  hypodermic  method 
that  has  rendered  such  great  service  to  ordinary 
medicine,  tends  to  come  more  and  more  into  use  in 
mental  medicine.  Already  for  a  long  time  M.  Aug. 
Voisin  has  recommended  morphine  injections  in  full 
doses  almost  as  a  regular  treatment  of  insanity. 
We  also  use  subcutaneous  injections  of  cocaine  in 
melancholia  (Morselli  and  Buccola) ;  injections  of 
ergot ine  and  ergotinine  in  the  congestive  attacks  of 
general  paralysis  (Christian,  Girma,  Descourtis) ; 
and  finally  injections  of  hyoscyamine,  hyoscine,  and 


OPERATIONS.  595 

duboisine  against  the  agitatioii  of  mania.  The 
hypodermic  method  is  the  better  for  the  insane  in 
that  it  overcomes  their  very  frequent  refusal  to  take 
medicine. 

Before  closing  the  subject  of  the  hyjjoderniic 
method  I  will  say  a  word  as  to  the  application  to 
mental  medicine  of  Brown-Sequard's  procedure,  that 
is,  the  subcutaneous  injection  of  the  testicular  extract. 
This  procedure  is  at  the  present  time  very  actively 
criticized  and  even  ridiculed,  but  it  would  be  rash, 
nevertheless,  to  affirm  that  it  can  never  give  any 
positive  results.  As  regards  psychiatry  in  particu- 
lar, it  appears  from  the  experiments  of  Professor 
Mairet  of  Montpellier  {Bull  Medical,  1890),  that 
the  testicular  liquid  has  a  favorable  influence  in 
melancholia  by  the  excitant  or  especially  the  tonic 
action  of  this  fluid  on  the  nervous  system.  I  believe, 
for  my  own  part,  that,  if  the  revivifying  effects 
attributed  to  this  method  are  real,  it  is  in  neurasthe- 
nia, the  malady  j>:>ar  excellence  of  nervous  exhaustion, 
and  in  psychic  and  physical  asthenia,  that  they 
ought  to  appear,  and  I  have  considered  the  possibil- 
ity of  making  trials  in  this  direction,  Avith  of  course 
all  due  cautions  and  reservations. 

Lavage  of  the  Stomach. — ^In  1880  I  recoiiiin(M-ided 
the  washing  out  of  the  stomach  for  thv  relief  of 
sitiophobia,  or  refusal  of  food  on  the  part  of  the 
insane,  and  this  measure  has  given  good  results  to  all 
those  who  have  tried  it  with  me,     Since  then  I  have 


596  TKEATMEXT  OF  EN-SANITY. 

endeavored  to  extend  this  method  to  the  treatment 
of  the  melancholia  itself,  which  arises,  as  we  are 
aware,  very  frequently  from  digestive  disorders, 
especially  from  a  gastro-intestinal  auto-intoxication, 
and  in  very  many  cases  I  have  been  able,  while 
relieving  the  bodily  symptoms,  to  concurrently  amel- 
iorate the  mental  condition.  The  capital  indication 
that  dominates  this  method  is  to  find  out  by  pre- 
vious chemical  examination  the  exact  composition  of 
the  gastric  juice,  and  consequently  the  nature  of  the 
co-existing  dyspepsia.  This  prior  investigation  in- 
deed should  guide  us  as  to  the  liquid  to  be  injected. 
Since  most  of  these  liquids,  especially  the  antiseptics, 
are  insoluble,  my  friend,  M.  Martial,  has  been  kind 
enough  to  furnish  a  series  of  formula?,  forming,  so 
to  speak,  the  posology  of  gastric  lavage.  They  will 
be  found  further  on,  in  the  list  of  therapeutic  re- 
ceipts which  terminate  this  chapter. 

Forced  Alimentation  or  "  Gavage''''  of  the 
Insane. — It  has  been  said  already  that  some  of  the 
insane,  mainly  of  the  melancholiacs,  hypochondriacs, 
and  the  cases  with  delusions  of  persecution,  obstin- 
ately refuse  all  nourishment.  This  is  what  we  have 
designated  as  sitiophobia.  In  these  cases  we  are 
compelled  to  make  them  take  food,  and  for  this 
purpose  have  recourse  to  forced  alimentation. 

Forced  feeding  of  the  insane  includes  a  host  of 
methods  of  every  kind  and  order.  The  most  prac- 
tical, and  we  may  say  the  only  one  used  m  rebellious 


OPERATIOlSrS. 


591 


cases,  is  oesophageal  catheterization.  T  will  not 
describe  this  in  detail,  but  will  confine  myself  to 
stating  here  the  principal  peculiarities  of  the 
raanipulatioD. 

CEsophageal  catheterization  in  the  sitiophobea 
should  always  be  practiced  by  the  nasal  fossae  and  not 
through  the  mouth,  on  account  of  the  difficulties 
met  with  in  the  latter  method.  The  patient  should 
be  seated  or  laid  on  a  bed,  the  head  sufficiently  ele- 
vated by  means  of  pillows.  If  he  is  too  violent  he 
can  be  restrained  with  a  camisole  or  lield  by 
attendants. 

The  instrument  that  should  be  employed  as  best 
for  the  purpose  is  a  thick-walled  rubber  tube  of _  a 
callibre  of  20  to  24  millimeters  and  of  considerable 
length.  After  dipping  it  into  warm  water  the 
operator  takes  it  like  a  pen  in  his  right  hand  at  a  dis- 
tance of  some  centimeters  from  its  lower  ex- 
tremity, and  introduces  it  gently  and  gradually 
into  the  nostril;  with  the  left  hand  he  covers  the 
patients  eyes  to  prevent  his  watching  the  movements 
and  thus  preventing  to  some  extent  his  voluntary 
resistance. 

The  principal  difficulty  in  catheterization  is  the 
arrest  of  the  tube  at  the  base  of  the  tongue,  which 
the  patient  frequently  holds  applied  against  the  pos- 
terior wall  of  the  pharynx.  This  is  a  very  serious 
obstacle.  The  difficulty  is  overcome  by  suddenly  in- 
jecting a  little  water  into  the  free  nostril :  the  reflex 
movement  of  swallowing  thus  produced,    opens  a 


598  TEEA^TMITNT  OF  IXSANITY. 

passage  for  the  tube  which  then  glides  down  if  the 
favorable  moment  is  taken  advantage  of. 

As  regards  the  diagnosis  of  the  tube  taking  a  false 
route  into  the  air  passages,  its  necessity,  fortunately, 
does  not  often  occur.  Nevertheless  it  may  happen. 
We  may  be  sure  that  the  tube  is  in  the  oesophagus, 
when  it  passes  without  effort  and  smoothly  in  a 
smooth  passage  free  from  asperities,  and  is  passed, 
in  spite  of  its  considerable  lengthy  clear  to  its  end  ; 
when  there  is  no  embarrassment  of  respiration  nor 
raucousness  of  the  voice  even  when  we  obstruct  the 
tube;  and  finally  when  we  hear  the  peculiar  noise 
of  the  exit  of  the  gas  from  the  stomach  at  the  open- 
ing of  the  tube.  For  greater  safety,  and  too  much 
precaution  cannot  be  employed,  we  may,  before  the 
injection  of  food,  turn  a  few  drops  of  water  into  the 
tube  and  notice  the  effect.  If  no  spasm  of  coughing 
and  nausea  is  produced  with  congestion  of  the  face 
and  efforts  to  get  rid  of  the  liquid,  we  may  be  almost 
certain  that  the  sound  is  in  the  cesophagus.  A  la 
rigneur^  we  may  use  either  the  sound  I  proposed 
under  the  name  of  sonde  d^epreiive^  or  the  more 
recent  one  of  M.  Raspail,  but  this  method,  T  admit, 
is  not  as  practical  as  might  be  wished. 

The  catheter  introduced,  the  alimentarj^  liquid  is 
injected,  but  is  preceded  each  time,  ac(;ording  to  the 
indications  laid  down,  b}''  washing  out  of  the  stomach. 
Formerly  I  employed  a  stomach  pump  for  this  pur- 
pose, but  have  long  since  replaced  this  slightly 
complicated  apparatus,  with  a  simple  Faucher  tube, 


MEDTCAMT!NT8.  599 

fitted  at  its  loose  end  by  means  of  a  grlass  tube  to 
oesophageal  sound  and  by  its  other  to  an  ordinary 
funnel.  I  thus  successively  and  conveniently  do 
iirst  the  washing  out  of  the  stomach,  and  then  the 
injecting  of  the  alimentary  fluid. 

The  nutritive  liquids,  prepared  in  advance  and 
warmed  to  the  temperature  of  the  bod}'-,  should  be 
made  up  of  varied  mixtures  of  milk,  bouillon,  eggs, 
peptones,  and  meat  powders,  Adrian's  complete  food, 
chocolate,  wine,  cod  liver  oil,  etc.,  to  which  we 
may  add,  according  to  the  case,  tonics,  preparations 
of  iron  and  other  drugs  that  seem  necessary.  I 
give,  further  on,  from  Lailler,  a  formula  for  alimen- 
tary liquid  for  the  feeding  of  the  insane. 

The  operation  should  be  repeated,  at  least  twice 
a  day. 

Phakmaceutical  Agents. 

The  medicines  used  in  the  treatment  of  insanity 
are  very  numerous,  and  their  number  increases  daily. 
Instead  of  giving  here  a  dry  and  necessarily  incom- 
plete list,  it  seems  to  me  preferable  to  give  first  a 
word  as  to  the  chief  classes  of  these  medicaments, 
and  then  to  add  a  short  therapeutic  formulary  of  the 
better  preparations  suited  to  each  type  of  the  disease. 

Purgatives. — Purgatives  have  been  always  em- 
ployed in  the  treatment  of  insanity.  They  are  used 
either  to  combat  constipation,  so  frequent  in  the 
insane,  or  to  act  by  a  salutaiy  derivation  on  the  in- 
testinal canal.  We  may  employ  indiscriminately  all 
kinds  of  purgatives  and  the  best  are  only  those  that 


600  TREATMENT  OF  INSANITY. 

are  easiest  administered ;  in  many  cases,  nevertheless, 
it  is  advisable  to  employ  drastics,  and  especially 
pills  with  a  basis  of  aloes,  which  have  the  effect  to 
congest  the  rectum  and  occasionally  may  even  re- 
establish a  suppressed  hemorrhoidal  flux. 

Sedatives.  Hypnotics. — Hypnotics  and  sedatives 
are,  with  purgatives,  the  drugs  most  frequently  em- 
ploj^ed  in  the  treatment  of  insanity.  Formerly  hardly 
any  others  than  oj^ium  and  morphine  were  in  use, 
but  of  latter  years  therapeutics  has  been  enriched 
with  a  number  of  different  agents,  at  once  less  dan- 
gerous and  more  eflicient.  Of  this  number  I  will 
cite  the  alkaline  bromides,  choral,  paraldehyde,  sul- 
fonal,  methylal,  hypnal,  hyoscyamine,  hyoscine,  etc. 

Tonics.  AntiperiocUcs. — Tonics,  such  as  quinine, 
arsenic,  alcohol,  iron,  bitters,  are  of  great  value  in 
the  insane,  who  are  often  subjects  of  anaemia.  Sul- 
phate of  quinine  has  been  recommended  in  certain 
periodical  psychoses,  notably  in  double  form  in- 
sanity and  in  malarial  insanity  where  it  seems  to 
have  had  good  effects. 

Diffusible  Stimulants.  Haschisch.  Eramena- 
gogues. — Among  other  drugs  suitable  for  more 
or  less  frequent  usage  in  the  treatment  of  insanity, 
I  will  mention  the  stimulants,  alcohol,  coffee,  tea, 
certain  special  products,  such  as  haschisch,  to  which 
has  been  attributed  from  the  first,  a  special  action  on 
hallucinated  subjects,  and  finally  emmenagogues, 
which  succeed  very  well  in  certain  cases  of  insanity 
due  to  amenorrhcea  or  dysmenorrhoia,  etc. 


THEBAPBUTIC  FOEMULABY.  601 


THERAPEUTIC  FORMULARY.* 

It  seemed  well  to  me  to  bring  together  here,  in 
such  a  way  as  to  be  of  use  to  the  practitioner,  some 
of  the  prescriptions  best  suited  for  the  treatment  of 
mental  diseases.  Some  of  them  are  taken  from  books, 
others  have  been  given  me  by  my  friends  MM. 
Carles,  Cathusier,  and  Martial,  to  whom  I  wish  to 
express  my  thanks.  These  formulas  are  classified 
according  to  the  mental  disorders  in  which  they  are 
especially  indicated,  but  it  is  needless  to  say  that 
they  may  be  used,  according  to  the  case,  in  any 
other  morbid  forms. 

MANIA. 

Sedatives  and  Hypnotics.  \ 

1 

Chloral 7        . 

Bromide  of  sodium \^^  ^^^^°^^- 

Syrup  of  orange  flowers  or  morphine .         30      " 
Distilled  water 100      " 

Fifty  centigrams  each  of  bromide  and  chloral  in  a  table- 
spoonful. 

1'  (YVON). 

Hydrate  of  chloral 5  grams. 

Bromide  of  sodium 5      " 

Syrup  of  codeine 15      " 

Note.— The  preparations  here  prescribed  are  largely  those  of  the 
French  pharmacopoeia.  The  prescriptions  are,  however,  all  intel- 
ligible and  it  will  be  easy  for  the  physician,  who  wishes  to  use  them, 
to  make  any  such  unimportant  changes  as  may  be  required  before  they 
can  be  filled  in  this  country.— Translator. 

tThe  best  of  the  known  hypnotics  for  the  insane  are:  sulfonal. 
chloral,  bromidia,  hyoscine,  hypnal,  methylal,  and  chloralamide. 
^BNT.  Mbd.— 38. 


602  TREATMENT  OF  DfSANlTY. 

Synip  of  cherry  laurel 15  grams. 

Distilled  water 120      " 

Fifty  centigrams  eacli  of  chloral  and  bromide  in  a  table- 
spoonful. 

2 

•Paraldehyde 10  grams. 

Alcohol 48      " 

Tincture  of  vanilla ,,  2      " 

Water 30      " 

Simple  syrup 60      " 

One  gram  of  paraldehyde  to  each  tablespoonful.     From 
one  to  six  spoonfuls. 

2'  (YvoN). 

Paraldehyde 1,  2.  3,  or  4  grams. 

Simple  syrup 30      " 

Water 70      " 

Tincture  of  cloves 20  drops. 

2"  (KJERAVAL  AND  NeRCAM)., 

Paraldehyde 2  grams. 

Yolk  of  egg 1 

Marsh  mallow  water 120  grams. 

For  an  injection. 

3 

Methylal 4  grams. 

Raspberry  syrup 20      " 

Distilled  water 100      '* 

Fifty  centigrams  of  methylal  to  a  tablespoonful.    Two 

spoonfuls. 

3 

Methylal 1  gram. 

Mucilage  and  water 125      " 

For  an  injection, 

4 

Sulfonal 1  gram. 

For  one  powder.     From  1  to  3  powders. 


THEBAPEUTIC  FOEMULABT.  603 

4 

Sulfonal,  finely  pulverized 6  grams. 

Powder  of  gum  arable 6      " 

Sugar 6      " 

Distilled  water 60      " 

One -half  gram  of  sulphonal  to  each  teaspoonful.     From 
one  to  three  teaspoonfuls. 

5  (Bromtdia). 

Chloral  hydrate 10  grams. 

Bromide  of  potassium. ...    10      " 

Extract  of  hyoscyamus 10  c'grams 

Extract  of  cannabis 10      " 

Distilled  water 30  grams. 

One  teaspoonful  every  hour  till  sleep  is  produced.     Give 

in  one-half  glass  of  sweetened  water. 

6 

Urethan 10  grams. 

Syrup  of  orange  flowers 30      " 

Distilled  water 120      " 

One    gram   of    urethan  to   a  tablespoonful.     From   one 
to  four. 

7 

Chloralamide 10  grams. 

Elixir  of  Gams 50      " 

Distilled  water 100      " 

One  gram  of  chloralamide    to  the  tablespoonful.     From 
1  to  4. 

8  (Latller). 

Hypnone 20  drops  or  50  centigrams. 

Alcohol 20  grams. 

Cherry  laurel  water 5      " 

Syrup  of  orange  flowers 275 

Sixty  grams  contain  4  drops  of  hypnoue. 

8  (Lailler). 

Hypnone 40  drops  or  1  gram. 

Alcohol 40  grams. 

Cherry  laurel  water 5      " 

Syrup  of  orange  flowers 255      " 


604 


TEEATME"NT  OF  INSANITY. 


Sixty  grams  contain  8  drops  of  hypnone.  If  onlj'  a  few 
drops  of  hypnone,  from  1  to  4,  use  formula  number  8,  if  8 
drops  is  prescribed,  use  formula  number  8'.  The  syrup  is 
poured  out  in  the  required  dose  into  a  150  gram  vial  which 
is  then  filled  with  water. 

9 

Ural 1  gram. 

For  one  powder.     From  1  to  4. 

9 

Ural 10  grams. 

Alcohol 10      " 

Syrup  of  punch 30 

Distilled  water 100      " 

One  gram  to  the  tablespoonful.    From  1  to  2. 

lO 

Hypnal 1  gram. 

For  one  pow^der.     From  1  to  2. 

lO 

Hypnal 10  grams. 

Alcohol 10      " 

Syrup  of  orange  flowers 30      " 

Distilled  water 100      " 

One  gram  to  the  tablespoonful.     From  1  to  3. 

11 

Hyoscyamine 10  milligr. 

Distilled  water 10  grams. 

For  hypodermic  injections.  One  syringeful  or  more  in 
a  day. 

12 

Chlorohydrate  of  hyoscine 10  milligr. 

Distilled  water  10  grams. 

From  i  to  1  syringeful.  Commence  with  i  or  :3r  and  keep 
it  up  till  2-5  or  I  of  a  milligram  is  reached.  The  amount  of 
1  milligr.,  1^  or  even  2  milligrams  may  be  gradually 
reached,  but  extreme  caution  should  be  employed  in  the  use 
of  these  large  doses. 


THERAPEUTIC  FORMULAEY.  605 

13 

Sulphate  of  duboisine 10  milligr. 

Distilled  water 10  grams. 

Maximum  dose  1  to  2  milligrams. 

MELANCHOLIA  OR  LYPEMANIA. 
14 

Treatment  of  Anxious  Lypemania  (Belle  and  Lemoine). 

a. — Rest  in  bed,  in  complete  dorsal  decubitus,  and  as 
prolonged  as  possible. 

h. — Each  morning,  on  awaking  and  before  eating,  a  glass 
of  purgative  water. 

c. — Tincture  of  nux  vomica  in  the  dose  of  five  drops,  each 
day,  divided  into  two  portions  and  taken  five  minutes  before 
each  of  the  two  principal  meals. 

d. — Laudanum  in  increasing  doses,  starting  with  five 
drops  daily  and  increasing  by  five  drops  each  day.  Given 
in  two  doses,  morning  and  evening. 

e. — Douches  with  interrupted  jet,  of  very  short  duration, 
and  only  after  the  bodily  health  has  become  good. 

15  (MOKSELLI  AND  BuCCOLA). 

Hydrochlorate  of  cocaine 1  gram. 

Distilled  water 100      " 

For  hypodermic  injections.     From  2^  to  10  milligrams. 

16 

Tonic  Wine. 

Wine  of  Kola  1 

"      "  cinchona  oka 

,<      t,         ,.  y 2d0  e'rams. 

"      "  gentian         [  .  » 

"      "  columbo      j 

Fowler's  solution 10      " 

Tincture  of  nux  vomica 5 

M.  S.     One  liqueur  glassful  twice  a  day  at  meal  times. 


606 


TREATMENT  OF  INSANITY. 


17 

Tonic  Pills. 

Extract  of  cinchona 5  grams. 

''Kola 5       " 

"rhubarb 2i     " 

"  nux  vomica 50  centigrams. 

Arseniate  of  iron 20  " 

Powder  of  Kola 9.5       " 

For  100  pills.     Four  pills  per  diem. 

18 

Gasti'o- Intestinal  Antisepsis. 

Beta-napthol  (precipitated) 10  grams. 

Salicylate  of  bismuth 10      " 

For  20  powders.    Two  a  day. 

19 

MecHcal  Washes  for  the  Stomach. 

a. — Cases  of  hyperacidity.     First  antiseptic  washing  out 
of  the  stomach  with : 

Creoline '     1  gram,  i 

Bicarbonate  of  soda 6      "      v  Emulsion. 

Water 1,000      "      ) 

Or :  Phenic  acid 1  gram,  \ 

Glycerine 10      "       [-Solution. 

Water 990      ".     \ 

Or:  Thymic  acid 1  gram.  ) 

Glycerine 10      "       \  Solution. 

Water 990      "       ) 

Or:  Corrosive  Sublimate 10  c'gr's.  \  q^i„x-  „  • 

Water 1,000  gr'ms.  [  Solution. 

Then  wash   out  with  alkaline  water,  or  simple  alkaline 
lavage  without  antiseptics. 

h. — Cases  of  anachlorohydria  and  of  dyspepsia  from  fer- 
mentation.    First,  antiseptic  lavage  of  the  stomach  with : 
Sah^^or pulverized  naphthol.  ^  ^^4 grams.  |  suspension. 

Or:  Resorcine 3 to  5  grams.  )  g^lution. 

Water 1,000  j 

Or:  Oxygenated  water. 


THERAPEUTIC  FOUMTTLAET.  607 


Or:  Iodoform,orpulverizediodol       1  gram.    )  suspension. 
Water 1,000  )        ^ 

Or:  Permanganate  of  potash.  •  -       10  cen'gr.  i  goi^tion. 
Water 1,000  grams.  ) 

Or:  Sodic  phenol  (plienate  of  soda)     10  grams.  I  Solution 

Water 1,000      "        ) 

or:  M^ylicadd, .............  ^^^^2  grams.  ^  g„,„„„„. 

"•"  wateVr:'::;:::;;;::;:;::  1,000  ^?"i  ««>"«-• 

Or:  Sulphate  of  copper  (pure). .        25  cen'gr.  )  q-,.. 
Water 1,000  grams,  f  »omuon. 

Then  washing  out  with  acid  wash : 

Hydrochloric  acid 4  grams.  )  goi^tion. 

Water 1,000  ) 

Or :  Lactic  acid. 20  grams.  )  solution. 

Water 1,000  ) 

Or  acid  drink  with : 

Hydrochloric  acid 2  grams. 

Simple  syrui3 100      " 

Alcoolature  of  oranges 40  drops. 

Water 890  grams. 

Or :  Lactic  acid 10  grams. 

Simple  syrup 100      ' ' 

Alcoolature  of  oranges 40  drops. 

Water 890  grams. 

20  (Lailler). 
Alimentary  Liquid  for  Forced  Feeding. 

Eggs 4 

Milk 2  litres. 

Claret 250  grams. 

Meat  powder 30      " 

DOUBLE  FORM  INSANITY. 

21   (HXJRD). 

a. — In  the  excited  stage,  hyoscy amine  or  hyoscine  hypo- 
dermically.     (See  numbers  11  and  12). 


60S  TREATMENT  OF  INSANITY. 

b. — In  the  depressed  stage: 

Citrate  of  Caffeine 1  gram. 

Syrup  of  codeine 30     " 

Distilled  water 90      " 

Tablespoonful  every  hour. 

Or :  Caffeine 3^  grams. 

Benzoate  of  soda 2|      " 

Distilled  water 6 

For  hypodermic  injections. 

PARTIAL  INSANITIES. 
Insomnia  of  Hallucinated  Cases. 

22  (LuYs). 

"Julep  gommeux  " 160  grams. 

Syrup  of  chloral 50      " 

Ergotine 30  centigrams. 

Tablespoonful  every  hour. 

NEURASTHENIA. 
23  (Dujakdin-Beaumetz). 

Ferro-potass._  tartrate )     ^^ 

Extract  of  cmchona )  ° 

Strychnia 5  centigrams. 

For  100  pills.    2  to  4  daily.     Use  also  tonic  preparations 

(Nos.  16  and  17). 

Sexual  Neurasthenia  (Beard  and  Rockwell). 

24 

a. — Tonic: 

Strychnia 15  milligrams. 

Phosphorus 15  " 

Extract  of  Indian  hemp 12  centigrams. 

Porphyrized  iron 2  grams. 

Powder  of  rhubarb 4 

M.   Make  into  25  pills,     3  daily. 


THERAPEUTIC  FORMULARY.  609 

h.  — Sedative : 

Bromide  of  zinc ^ 

Valerianate  of  zinc -    aa.  1  gram. 

Oxide  of  zinc ) 

Conserve  of  roses q.  s. 

For  20  pills.     3  each  day. 

GENERAL  PARALYSIS. 

For  the  Congestive  Attacks, 

25  (Tauret). 

Ergotiuine 5  centigrams. 

Lactic  acid 10         ' ' 

Distilled  water 5  grams. 

Syrup  of  orange  flowers 995      " 

Contains  ^  milligram  of  ergotinine  to  eacli  teaspoonful. 

25'  (Tauret). 

Ergotinine 1  centigram. 

Lactic  acid 2  "  • 

Cherry  laurel  water 10  grams. 

About  one  milligram  of  ergotinine  to  a  hypodermic  syringe. 
Dose :  from  ^  milligram  to  1  milligram. 

26 

Treatment  of  the  DecuMtiis: 

a. — Erythematous  period. — Classic  application  of  diachylon 
plaster  to  prevent  contact  of  the  skin  with  the  surface  of  the 
bed.  ^  Billroth  advises  soap  plaster  as  follows: 

Soap  plaster 50  grams. 

Spread  on  a  piece  of  soft  leather  or  line  cloth. 

h. — Oangrenous  period. — The  separation  of  the  slough  is 
facilitated  by  tampons  of  wadding  soaked  with  antiseptic 
applications  like  the  following: 

Phenic  acid 5  grams. 

Olive  oil 300      " 

Or  we  may  dust  the  surface  with  finely  pulverized  iodo- 
form and  cover  with  iodoform  gauze,  or  we  may  employ 
compresses  saturated  with : 

Permanganate  of  potash 60  centigrams. 

Distilled  water 500  grams. 


Cbapter  ID, 

MEDICO-MEISTTAL   DEONTOLOGY. 

It  sometimes  happens  in  professional  practice  that 
the  physician  is  consulted  in  regard  to  certain  deli- 
cate questions  bearing  especially  on  the  heredity  of 
alienation  and  the  results  that  may  follow  in  the 
families  of  the  patients.  The  role  of  expert  is  not 
always  an  agreeable  one  in  these  cases,  nor  is  his 
intervention  altogether  easy.  It  seems  worth  while 
therefore  to  indicate  some  of  the  points  the  knowledge 
of  which  may  facilitate  his  task  in  such  a  case.  The 
principal  questions  to  be  answered  in  this  connection 
are  the  following :  (1)  That  of  the  sexual  relations 
between  an  insane  person  and  his  or  her  consort;  (2) 
The  chances  of  heredity  of  the  different  members  of 
the  family  of  an  insane  person ;  (3)  The  marriage  of 
the  insane  and  of  those  related  to  them. 

1.  Sexual  relations  between  the  insane  individ- 
ual and  his  or  her  married  partner. — The  solution  of 
this  question,  which  is  often  very  embarrassing,  may 
be  imposed  upon  the  physician  under  two  quite  differ- 
ent conditions:  a. — during  the  existence  of  the  dis- 
order itself;  b. — after  its  cure. 

a. — In  the  first  case  we  have  to  deal  either  with 
an  individual  who  is  being  treated  in  some   way  or 


CONJUGAL  RELATIONS  OF  THE  INSAlSrE.  611 

Other  at  his  home  and  who  lives  in  more  or  less  close 
contact  with  his  family,  or  with  a  patient  confined 
in  a  special  establishment,  and  who,  for  various 
reasons,  is  permitted  interviews  and  promenades 
with  his  or  her  consort.  As  a  rule  the  physician  is 
not  consulted  in  regard  to  their  conjugal  relations, 
which  take  place  or  not  without  his  intervention; 
occasionally,  nevertheless,  he  is  called  upon  to  give 
his  opinion  as  to  their  safety  and  the  inconveniences 
to  which  they  may  give  rise.  The  response  of  the 
medical  adviser  in  such  cases  should  be  positive ;  it 
is  self-evident  that  he  ought  to  formally  prohibit  all 
sexual  relations  between  the  parties,  not  only  as  a 
cause  of  excitement  or  exhaustion  of  the  patient,  but 
also  as  dangerous  in  view  of  possible  procreation ;  it 
being,  in  fact,  admitted  that  children  of  a  parent 
deranged  at  the  time  of  conception  are  especially 
exposed  to  become  insane.  This,  moreover,  is  one 
of  the  thousand  reasons  why  isolation  is  necessary  in 
cases  of  this  kind,  as,  while  the  insane  person  con- 
tinues to  live  with  his  family,  difiiculties  of  every 
kind  are  met  with  and  it  becomes  less  easy  to  suc- 
cessfully oppose  his  desires  and  inclinations.  In 
any  case  it  is  the  correct  thing  to  absolutely  forbid 
sexual  relations  between  two  persons,  one  of  whom 
is  at  the  moment  suffering  from  an  attack  of 
insanity. 

h. — The  case  is  different  after  the  patient  has  re-, 
covered,  and  it  seems  to  me  altogether  arbitrary  to 
oppose,  as  has  sometimes  been  done,  and  recently  in 


612  MEDICO-MENTAL  DEONTOLOGY. 

a  case  under  my  own  observation,  the  legitimate  de- 
mands of  an  individual  restored  to  reason,  and  con- 
sequently in  full  possession  of  his  conjugal  rights. 
I  certainly  do  not  ignore  the  fact  that  sexual  rela- 
tions of  ex-insane  individuals  are  dangerous  in  a 
social  point  of  view,  but  in  spite  of  all  considera- 
tions, it  is  not  evident  that  we  have  any  right  to 
restrain  them,  any  more  than  we  have  in  the  case  of 
a  consumptive  or  any  other  individual  the  subject  of 
a  diathesis  transmissible  to  his  descendants.  If 
mental  derangement  has  its  dangers,  the  constitu- 
tional diseases  of  a  physical  order  have  theirs  also, 
and  we  cannot  make  an  exception  as  regards  the 
former,  which  shares  the  common  rights.  The 
physician  should  bear  this  in  mind  when  called  to 
give  his  opinion  on  this  point.  It  is  his  duty,  never- 
theless, to  act  with  prudence  and  to  try  to  attenu- 
ate, to  some  degree,  the  possible  consequences  of 
sexual  approaches  in  such  conditions,  by  delaying 
them  till  the  cure  is  absolute,  and  by  advising  the 
patient  in  the  interest  of  his  future  health,  to  use 
the  greatest  moderation  in  the  accomplishment  of  his 
desires.  As  to  those  methods  of  rendering  the  con- 
jugal relations  without  effect  as  regards  procreation, 
too  much  employed  at  the  present  time,  I  do  not 
believe  that  it  appertains  to  the  physician  to  inter- 
vene in  regard  to  them,  still  less  to  advise  their  use, 
in  these  cases;  since  here  we  touch  a  very  delicate 
point  and  one  that  is  completel}'  outside  of  the 
medical  jurisdiction. 


CHANCES  OF  HEREDITY.  613 

2.  Chances  of  Heredity  of  various  members  of  the 
Family  of  an  Insane  Person. — In  a  session  of  the 
Medico-psychological  Society,  Billed  judiciously 
brought  up  the  following  question  of  medico-mental 
practice:  "What  should  be  our  conduct  when  con- 
sulted by  a  person  who  believes  himself  threatened 
with  insanity  because  he  is  the  offspring  of  insane 
parents?  "  This  communication  and  the  succeeding 
discussion  resulted  in  the  rather  general  conclusion 
that  the  duty  of  the  physician  in  such  a  case  is  to 
reassure  his  client,  while  at  the  same  time  maintain- 
ing a  great  reserve.  It  is  true  that  this  is,  in  fact, 
the  position  the  physician  ought  to  take,  and  that  he 
ought  no  more  to  increase  the  fears  of  a  child  of  an 
insane  person  than  he  should,  for  example,  those  of 
the  offspring  of  a  consumptive  who  fears  that  he  in 
turn  may  become  tuberculous.  This,  however,  is 
only  a  general  indication,  and  the  question  has  other 
aspects  that  have  been  passed  over  in  silence,  but 
which,  nevertheless,  it  is  useful  to  solve.  Thus  we 
may  be  consulted  not  merely  by  the  descendant  of 
an  insane  person :  it  may  not  be  the  interested  party 
himself,  but  one  of  his  near  relatives  or  his  wife ;  by 
a  mother,  for  example,  who  is  disquieted  about  the 
future  of  her  child,  or  by  a  wife  who  wishes  to  know 
the  dangers  that  threaten  her  husband.  In  short, 
cases  may  happen  where  the  physician  is  compelled 
not  to  reassure  but  to  speak  with  freedom  and  to 
make  the  reasons  for  his  opinion  appreciable.  On  the 
other  hand,  it  seems  to  me  that  his  answer  should  not 


614  MEDICO -MENTAL,  DEONTOLOGY. 

be  indiscriminately  the  same  for  all  cases,  and  that 
he  ought  not,  for  example,  to  apply  the  same  path- 
ological probabilities  to  the  descendant  of  a  general 
paralytic  as  to  the  son  of  a  lypemaniac  or  a  subject 
of  delusions  of  persecution,  for  the  simple  reason 
that  the  different  forms  of  derangement  do  not 
expose  all  to  the  same  degree  or  type  of  heredity. 
It  is  right,  therefore,  when  called  upon  to  decide  the 
question  of  the  chances  of  heredity  in  mental  aliena- 
tion, to  not  limit  oneself  to  the  task  of  allaying  more 
or  less  well  founded  apprehensions,  but  to  formulate 
a  scientific  and  rational  opinion  based  in  particular 
upon  certain  considerations  relative  to  (a)  the  person 
inquiring;  (b)  the  one  about  whom  inquiry  is  made; 
and  (c)  the  form  of  mental  derangement  that  exists. 

(a). — As  regards  the  person  making  the  inquiry, 
there  are,  properly  speaking,  no  special  considera- 
tions to  be  kept  in  mind  and  the  general  principles  of 
propriety  that  apply  in  ordinary  medical  practice  are 
equally  applicable  in  mental  medicine.  It  suffices  to 
say  that  when  one  is  consulted  by  the  interested 
party  himself,  it  is  frequently  necessary  to  dissimu- 
late and  to  avoid  darkening  the  future,  since  even 
the  distant  prospect  of  dreaded  evil  may  be,  so  to 
speak,  fatal.  On  the  contrary,  when  we  are  dealing 
with  another  than  the  one  directly  involved,  we  can 
express  ourselves  more  unreservedly,  especially  if  the 
object  is  to  institute  a  preventive  treatment  capable 
of  lessening  to  some  extent  the  chances  of  insanity. 


CHANCES  OF  HEREDITY.  615 

(b). — The  considerations  relative  to  the  person 
whose  chances  of  heredity  are  involved  are  derived 
chiefly  from  his  degree  of  relationship  with  the 
insane  person  or  persons  existing  in  tlie  family  line, 
and  also  from  his  bodily  and  mental  constitution. 
It  is  clear  that  the  closer  the  relationship  is  the 
greater  are  the  chances  of  heredity.  The  son  and 
daughter  are  therefore  more  exposed  than  the  brother 
and  sister,  these  again  more  than  the  nephew  and 
niece,  and  these  last  more  than  the  cousins  in  all 
degrees.  The  children  also  are  more  exposed  when 
insanity  exists  in  the  mother  than  when  it  is  in  the 
father,  and  among  the  children  of  the  same  insane 
parent,  those  born  at  a  period  nearest  the  parents 
insanity  have  also  the  more  chances  against  their 
future.  Lastly,  it  is  claimed  that  insanity  of  the 
father  is  more  frequently  transmitted  to  the  daugh- 
ters and  that  of  the  mother  to  the  sons,  a  fact  that 
is  far  from  being  demonstrated ;  neither  is  it  estab- 
lished sufficiently  that  the  children  who  physically 
resemble  one  of  their  parents  also  take  after  that 
one  in  a  psychic  point  of  view,  and  in  consequence 
have  a  more  marked  tendency  to  inherit  his  or  her 
mental  disorders. 

As  regards  temperament,  the  bodily  and  mental 
constitution  of  the  party  interested,  it  is  clear  that  we 
have  here  an  important  element  and  one  that  should 
be  duly  estimated  in  the  calculation  of  the  morbid 
probabilities  for  the  individual.  We  are  well  aware 
that  all  the  members  of  the  families  of  the  insane  are 


610  MEDICO-MENTAL  DEOKTOLOGT. 

not  alike  doomed  to  become  insane,  and  that,  together 
with  ill-balanced  or  insane  members,  there  are  others 
whose  mental  make  up  is  normal  and  not  in  the 
least  degree  affected.  But  among  these  different 
types  of  which  these  families  are  composed,  it  is,  as 
a  rule,  rather  easy  to  distinguish  those  of  healthy 
mental  constitution  from  the  candidates  for  insanity. 
These  last  may  be  marked,  even  at  a  very  early  age, 
by  an  absolute  lack  of  equilibrium  in  their  faculties, 
by  a  lack  of  balance  and  harmony,  the  absence  of 
sequence  in  their  ideas  and  of  logic  in  conduct,  by  a 
manifest  predominance  of  the  nervous  temperament, 
a  morbid  impressionability,  a  marked  tendency  to 
excitement  or  depression  from  the  slightest  causes, 
sometimes  alternations  of  excitement  and  depression. 
The  others,  on  the  contrary,  are  always  well  poised 
and  masters  of  themselves,  and  we  realize  in  their 
presence  that  they  are  normal  individuals,  sharing 
little  or  none  of  the  pathological  heritage.  The 
difference  will  be  still  more  pronounced  if  the  children 
of  the  insane  already  arrived  at  adult  age  have  their 
temperament  clearly  marked ;  the  ones  have  already 
given  evidence  of  some  cerebral  trouble  either  at  an 
early  age  or,  what  is  more  frequent,  at  puberty  or 
the  first  serious  emotions  of  life  ;■  the  others,  on  the 
contrary,  have  already  passed  the  various  stages 
without  having  felt  the  least  inental  disturbance  or 
undergone  the  slightest  moral  shock.  In  a  word,  it 
is  necessary  to  submit  the  individual  in  regard  to 
whose  future  we  are  consulted,   either  directly  or 


CHAiq'CES  OF  HEREDITY.  617 

indirectly,  to  a  minute  psychological  analysis,  just  as 
we  would  submit  to  an  attentive  pulmonary  exam- 
ination any  descendant  of  a  consumptive  who  might 
be  disturbed  as  to  his  lungs. 

(c) .  — The  most  important  element  however  in  this 
question  is,  without  dispute,  the  study  of  the  type  of 
mental  alienation  in  the  case. 

First  of  all,  is  it  an  isolated  case,  unique  in 
the  family,  or,  on  the  other  hand,  are  there  many 
similar  ones,  giving  evidence  that  the  evil  is  already 
deep-rooted  and  that  the  taint  is  destined  to  be  trans- 
mitted from  generation  to  generation?  Does  the 
mental  alienation  exist  on  one  side  only,  or  on  both, 
paternal  and  maternal,  at  the  same  time?  Are 
there  already  in  the  existing  generation  to  which 
the  suspected  person  belongs,  any  examples  of  ec- 
centricity, neuroses,  insanity,  mental  degeneracy,  or 
on  the  contrary  are  the  signs  those  of  a  normal  con- 
stitution? Was  the  disease  of  the  ancestor  purely  an 
unforeseen  accident,  occasioned  by  powerful  causes 
altogether  personal  in  their  nature,  or,  on  the  other 
hand,  did  it  appear  under  the  influence  of  some 
trivial  cause,  acting  on  an  already  existing  predis- 
position? All  these  are  so  many  important  points 
which  call  for  close  attention. 

Lastly,  and  this  is  a  capital  point,  in  my  opin- 
ion, although  it  was  not  taken  into  account  in  the 
discussion  cited  above,  it  is  important  to  specify 
clearly,  before  pronouncing  an  opinion,  the   charac- 

Ment.  Med.— 39. 


618  medico-:mental  deontology. 

ters  and  the  form  of  the  mental  derangement  that 
existed  in  the  ancestors.  We  are  not  to  think, 
in  fact,  that  it  is  a  matter  of  indifference,  as 
regards  morbid  consequences,  whether  we  have 
to  deal  with  this  or  that  form  of  insanity, 
and  the  memoirs  on  heredity  and  on  the  biol- 
ogical constitution  of  families  that  have  followed 
those  of  Lucas,  Morel,  Moreau  (deTours)  have  al- 
ready clearly  laid  down  the  fundamental  distinctions 
that  are  usefully  applicable  in  this  point  of  view  in 
practice. 

We  know,  in  the  first  place,  that  certain  forms  of 
mental  alienation  predispose  more  than  others  to 
heredity,  and  that  suicide,  double  form  insanity, 
the  reasoning  insanities,  intermittent  or  periodical 
insanities,  to  mention  only  these,  almost  inevitably 
expose  the  descendants,  while  certain  others,  like 
acute  mania  and  melancholia  compromise  the  future 
of  the  family  to  a  much  less  degree.  We  are  also 
aware,  and  this  is  what  M.Bali  and  I  have  especially 
endeavored  to  show  in  our  work  on  the  biological 
characters  of  the  families  of  the  insane,  that  hered- 
ity, in  mental  alienation,  presents  itself  under  three 
morbid  types  with  clearly  defined  characteristics, 
although  similar  in  appearance:  (1)  the  neurotic  or 
neuropathic  type  which  originates  in  the  neuroses, 
and  gives  rise  to  neuroses  and  neuropathic  insanity; 
(2)  the  cerebral  or  congestive  type,  originating  in 
cerebral  disorders,  properly  so-called,  and  giving 
rise  to  cerebral  affections,  complicated  or  otherwise 


CHANCES  OF  HEREDITY.  619 

with  insanity;  (3)  the  vesanic  type,  originating  in 
the  vesanias  or  insanities,  properly  so-called,  and 
giving  rise  also  to  vesania,  that  is,  to  pure 
insanity.  The  special  evolution  of  the  morbid  man- 
ifestations of  each  of  these  hereditary  types,  per- 
mits therefore,  to  a  certain  extent,  the  foretelling 
to  what  category  of  mental  disorders  the  members 
of  a  family  are  particularly  exposed.  Thus,  for 
example,  when  the  individual  in  any  special  case 
of  inquiry  is  a  descendant  of  a  general  paralytic,  the 
answer  of  the  physician  will  not  be  the  same  as 
when  questioned  in  regard  tp  the  son  of  a  vesaniac. 
The  following  are  the  terms  in  which  M.  Ball  and  I 
formulated  our  opinion  in  this  regard:  "  Thus  gen- 
eral paralysis  does  not  arise  from  insanity  and  does 
not  engender  insanity.  Like  the  cerebral  diseases, 
it  is  born  of  cerebral  affections  and  gives  rise  to  the 
same." 

"It  follows  that  general  paralytics,  not  being 
descendants  of  the  insane  nor  producing  lunatics,  the 
children  of  these  patients  escape  vesanic  heredity,  and 
that  if  they  are  doomed  to  a  special  class  of  diseases 
by  reason  of  the  general  paralysis  of  their  father  or 
their  mother,  it  is  evidently  not  to  insanity  but  to 
cerebral  affections  of  all  kinds. 

"Thus,  when  consulted,  and  this  happens  daily, 
in  regard  to  the  future  of  a  child  of  a  general  para- 
lytic, the  opinion  of  the  physician  should  be  the 
direct  opposite  to  that  usually  given  by  practitioners 
or  even  by  specialists  more  acquainted  with  these 


620  MEDICO-MENTAL  DEONTOLOGY. 

subjects,  namely,  that  the  child  of  a  general  paralvtic, 
hj  the  mere  fact  that  he  is  a  general  paralytic  is  in 
no  way  predisposed  to  insanity,  that  he  has  only  to 
fear  from  predisposition  cerebral  disorders,  and  that 
therefore  the  two  critical  periods  of  his  life  are 
infancy,  on  account  of  the  tendency  to  infantile 
cerebral  disorders  at  this  time,  and  adult  age,  the 
period  for  cerebral  paralysis  and  for  general  paralysis 
itself. 

"Altogether  the  future  is  thus  much  more  re- 
assuring, with  the  more  reason  since,  very  different 
from  the  families  of  vesaniacs  in  which  cases  of  insan- 
ity are  constantly  on  the  increase,  the  families  of  para- 
lytics rid  themselves  in  infanc}'-  of  their  worse  con- 
tingent and  are  purified,  so  to  speak,  under  the 
influence  of  infantile  brain  disorders ;  so  that  these 
families  are  thus  regenerated,  if  we  can  so  express  it, 
by  a  sort  of  morbid  selection,  and  what  remain  of  the 
descendants  of  the  paralytics  may  be  considered  as 
almost  normal." 

On  the  other  hand,  if  we  have  a  family  in  which  are 
many  cases  of  insanity,  properly  so-called,  or  vesania, 
we  have  also  to  fear  vesania  in  the  descendants,  from 
the  fact  that  in  vesanic  heredity  it  fs  the  repeated 
aptness  to  insanity  that  constitutes  in  each  generation 
the  characteristic  of  its  morbidity.  The  same  is  true 
of  the  families  of  the  neuropaths  or  neurotics,  in  whom 
the  type  of  neuropathic  heredity  reveals  itself  with 
its  special  characters. 

It  is  sometimes  possible,  however,  to  carry  scien- 


MAEEIAGE8  OF  THE  INSANE.  621 

tific  induction  still  farther  in  the  calculation  of  the 
morbid  probabilities.  It  is  not  only  possible  to  almost 
certainly  determine  in  advance  to  which  of  the  three 
types  of  heredity  the  individual  in  question  belongs, 
but  also,  in  special  cases,  to  just  what  variety  of 
insanity  he  is  most  likely  to  succumb.  Thus,  for 
example,  the  children  of  suicides  are  often  impelled  to 
suicide  themselves,  and  the  children  of  subjects  of 
double  form  insanity  are  also  liable  to  have  the  same 
form  as  their  progenitor  in  preference  to  any  other. 
It  will  thus  be  seen  what  interesting  consider- 
ations arise  from  these  questions  of  medico-mental 
deontology.  Also,  although  the  biological  study  of 
the  family  history  of  the  insane  of  these  different 
types  has  hardly  been  more  tl>an  touched  upon, 
the  practical  conclusions  we  can  deduce  from  the 
facts  gained  are  already  very  important,  and  enable 
the  physician,  in  the  cases  we  have  in  view,  to  fonii- 
ulate  a  scientific  and  rational  opinion,  and  not 
merely  a  response,  empirical  so  to  speak,  and  made 
solely  to  reassure  the  interested  parties. 

3.  Marriages  of  the  Insane  and  Relatives  of 
the  Insane. — The  phj^sician  may  be  consulted  as  to 
the  propriety  of  marriage,  in  psychiatric  practice, 
either  relative  to  the  insane  themselves  or  their 
relatives. 

a, — As  regards  the  insane,  it  is  mainly  with  those 
that  have  recovered  from  their  insanity  that  we  have 


622  MEDICO-MENTAL  DEOIfTOLOGY. 

to  do,  since  the  marriage  of  a  lunatic  during  the 
existence  of  his  disorder  could  hardly  be  suggested 
except  under  very  uijusual  circumstances.  Some 
cases  have  occurred,  nevertheless,  where  the  mar- 
riage of  insane  persons  confined  in  special  establish- 
ments has  been  authorized  and  recognized  as  valid,  as 
was  shown  in  the  interesting  discussion  that  occurred 
on  this  subject  in  1876  in  the  Societe  Medico-psy- 
chologique.  As  regards  non-sequestrated  lunatics, 
their  marriage  presents  much  fewer  difficulties, 
and  cases  exist,  as,  for  example,  a  union  in  extremis 
intended  to  correct  an  abnormal  situation,  and,  as 
under  some  other  circumstances  still,  where  the  doc- 
tor can  give  his  approval  to  such  a  marriage.  But, 
apart  from  these  altogether  exceptional  cases,  the 
practitioner  should  be  prudent  and  should  keep  him- 
self apart  from  marriages  of  lunatics,  which  often 
conceal  interested  motives  and  unavowable  specula- 
tions. 

The  question  of  the  marriage  of  a  recovered  luna- 
tic occasionally  comes  before  us,  and  Morel  says, 
in  this  connection,  that  he  has  been  able  to  decide 
boldly  in  favor  of  it,  when  the  individuals  concerned 
had  no  case  of  insanity  in  their  ancestors  and  when 
their  disorder  broke  out  under  the  influence  of  a 
moral  cause  personal  to  themselves. 

It  should  be  added  that  the  marriage  can  hardly 
be  approved  of  in  these  cases,  except  when  the  in- 
sanity was'^merely  an  acute  attack  of  melancholia  or 
especially  of  mania,  the  only  forms  of  mental  alien^ 


MARRIAGES  OF  THE  INSANE.  623 

ation  of  which  recovery  may  be  sufficiently  certain  to 
not  compromise  the  future  of  the  ex-lunatic.  Never- 
theless, however  accidental  the  attack  of  insanity, 
and  however  little  hereditary  it  may  appear,  the 
physician  ought  conscientiously  to  formulate  some 
reservations  even  while  giving  a  favorable  opinion. 

It  is  chiefly  in  regard  to  the  marriage  of  the  rela- 
tives of  the  insane,  however,  that  the  question  is  raised 
in  medico-mental  practice.  Usually  it  is  the  descend- 
ant of  an  insane  person  who  inquires,  or  for  whom  a 
relative  asks  whether  or  not  he  can  marry  with 
impunity,  and,  still  m.ore  commonly,  a  strange  lady 
who  wishes  to  know  in  behalf  of  one  of  her  family 
whether  she  can  seek  an  alliance  with  the  descendant 
of  a  lunatic.  Here  is  a  delicate  matter,  and  one  in 
which  the  physician  cannot  exercise  too  much  circum- 
spection and  too  much  reserve.  As  in  case  of  the 
preceding  question,  he  ought  to  chieflj^  base  his 
answer  on  considerations  relative  to  the  person  inquir- 
ing, the  party  interested,  and  the  malady  in  question. 

W  hen  the  person  chiefly  interested  is  the  one  who 
consults,  the  condition  is  frequently  embarrassing, 
since  the  physician  cannot  have  with  him  his  full 
liberty  of  action.  He  ought,  therefore,  to  try,  under 
some  pretext  or  other,  in  this  case,  to  consult  with 
some  other  member  of  the  family,  with  whom  he  will 
find  himself  in  a  more  independent  situation.  In 
case,  moreover,  where  this  is  impossible  and  the 
physician  finds  himself  obliged  to  advise  against  mar- 
riage to  a  descendant  of  a  lunatic,  he  should  support 


624  MEDICO-MENTAL  DEONTOLOGY. 

his  opinion  with  the  argument  that  although  alto- 
gether free  from  the  disorder  of  his  father  or  mother, 
the  individual  runs  the  risk  of  transmitting  the  pre- 
disposition to  his  own  offspring  by  a  fact  of  atavism, 
and  that  in  consequence  it  would  be  better  for  him  to 
abstain  from  marriage.  He  may  also  try  to  induce 
him  to  defer  his  marriage  when  it  is  possible,  and  to 
wait  till  the  period  when  mature  age  has  placed  him  to 
a  certain  extent  beyond  the  risk  of  acute  attacks 
of  insanity,  which  are  much  most  frequent  in 
youth.  Finally,  when  the  case  requires  it,  he  can 
base  his  prohibition  on  some  other  morbid  peculiar- 
ity, for  example,  a  too  feeble  physical  constitution, 
or  a  moral  temperament  ill  fitted  for  domestic  life. 

When  it  is  a  father  or  mother  or  some  more  dis- 
tant relative  that  consults  in  behalf  of  the  party  in- 
terested, we  can  be  more  frank,  while  still  maintain- 
ing some  reservations.  It  will  be  permissible, 
nevertheless,  to  express  one's  opinion  with  more 
freedom. 

Finally,  it  may  happen  that  strangers  come  to  de- 
mand of  the  physician  an  opinion  as  to  whether  they 
can,  without  peril,  permit  for  one  of  their  family  an 
alliance  with  the  offspring  of  a  lunatic.  It  is  under- 
stood that  I  do  not  refer  here  to  any  strangers  that 
might  ask  the  practitioner  to  commit  an  indiscretion 
or  violate  medical  confidence,  but  to  persons  already 
in  relations  with  the  family  of  the  interested  party, 
and  who  come  with  its  authorization  to  inquire  in 
regard  to  a  matter  in  which  they  are  deeply  inter- 


MARRIAGES  OF  THE  INSANE.  625 

ested.  In  this  case  the  physician  is  free  to  act  since 
he  has  permission  to  express  himself  freely,  preserv- 
ing of  course  all  the  reserve  and  delicacy  that  should 
never  be  lacking  in  matters  of  this  nature. 

As  to  the  considerations  relative  to  the  interested 
party  himself  and  to  the  form  of  derangement  exist- 
ing in  his  family,  they  are  exactly  the  same  as  those 
brought  out  in  the  preceding  question,  since  here 
again  it  is  the  estimation  of  the  chances  of  heredity 
that  is  asked  for.  We  will  pass  therefore  in  review 
the  degree  of  the  relationship  of  the  individual  with 
the  insane  patient,  his  constitution,  his  temperament 
and  his  antecedents,  as  well  as  the  characters  of 
multiplicity,  of  intensity  of  origin,  and  of  form  of 
the  mental  derangement  that  existed  in  the  ancestor. 
Especially  will  we  not  forget  the  distinction  we  have 
made  between  the  three  different  forms  of  heredity 
nor  to  deduce  the  consequences  tliat  follow  from  it. 
Thus,  for  example, — I  again  quote  from  our  memoir 
— "if  one  is  consulted  on  the  subject  of  a  union  to  be 
contracted  by  or  with  a  descendant  of  a  general  para- 
Ijtic,  he  may  boldly  give  to  that  union  his  medical 
and  scientific  approbation,  b}^  affirming  that  general 
paralysis  is  solely  a  cerebral  disease,  and  for  that 
reason  does  not  create  a  predisposition  to  insanity 
in  the  descendants." 

And,  if  it  is  required  of  me,  in  concluding,  to  sum 
up  in  a  few  words  the  practical  consequences  of 
this  biological  study  we  have  made,  I  would  say : 

"If  one  wished  to  save  his  children  from  the  sad 


626  MEDICO-MENTAL  DEONTOLOGY. 

inheritance  of  insanity   he  might    with  impunity,  I 

believe,  enter  into  the  family  of  a  general  paralytic, 

but  it  is  always  dangerous  in  this  case  to  espouse  the 

daughter  of  a  lunatic." 

It  is  not  a  matter  to  be  neglected  when  we  come 

to  pronounce  in  regard  to  the  safety  or  propriety  of 
the  marriage  of  the  descendant  of  an  insane  person, 
to  study,  as  far  as  possible,  the  family  with  which 
he  thinks  of  allying  himself,  and  especially  the  tem- 
perament of  his  future  consort.  It  is  clear,  in  fact, 
that  the  union  will  offer  much  fewer  dangers,  as  re- 
gards the  offspring,  in  cases  where  the  marriage 
produces  a  happy  crossing,  while  the  existence  of  a 
like  predisposition  in  the  future  married  pair  will, 
on  the  contrary,  be  a  formal  indication  for  the  scien- 
tific opposition  of  the  phj^sician. 

Such  are  the  principal  questions  of  medico-mental 
deontology  that  the  physician  is  called  upon  to  solve 
in  practice.  Still  others  might  be  presented,  but 
their  importance  is  less  great,  and  they  therefore  do 
not  seem  to  me  to  call  for  a  special  study. 


SECOND   SECTION. 


MEDICO-LEGAL  PRACTICE. 

While  the  medical  practice  of  mental  alienation  has 
not,  prior  to  the  present  period,  been  the  subject  of 
special  works,  medico-legal  practice  on  the  other  hand 
has  always  attracted  the  attention  of  observers,  and 
there  exist  in  this  department  a  considerable  number  of 
very  important  works,  from  the  treatises  of  Zacchias, 
Hoffbauer,  Fodere,  Mitterraaier,  Georget,  Marc, 
Casper,  down  to  the  more  recent  ones  of  Bonnucci, 
Tardieu,  Legrand  du  Saulle,  and  Krafft-Ebing, 
without  mentioning  the  articles  scattered  through 
the  cyclopedias  and  reviews,  among  which  I  will  cite 
only  those  of  M.  J.  Falret,  of  Linas,  of  M.  Motet 
and  M.  Ritti.* 

Also,  without  entering  into  historical  develop- 
ments or  scientific  discussions,  for  which  we  refer 
the  reader  to  the  works  already  cited  and  to  the 
majority  of  the  general  treatises  on  legal  medicine, 
we  confine  ourselves  to  summing  up  in  a  practical 

♦Consult  also,  for  the  general  questions  relative  to  the  legal  med- 
icine of  insanity:  Maudsley,  Crime  and  Insanity;  Max  Simon,  Ci'imea 
et  Delits  dans  la  Folie;  Cullerre,  les  Frontieres  de  la  Folie;  Parnnt,  la 
liaison  dans  la  Folie;  Ball,  Lemons  sur  les  Maladies  Mentales,  '2d  edition; 
F6r6,  Deg'enerescence  et  Criminalite;  Lombroso,  VHomme  Criminel; 
Tarde,  Cnminalite  GompaHe;  Coutagne,  la  Folie  au  point  devucjudi- 
ciare  et  administratif;  the  woi'ks  of  Garofalo,  Ferri,  Sergi,  lastly  the 
Comptes  Rendus  of  the  International  Congress  of  Legal  Medicine, 
Mental  Alienation  and  Criminal  Anthropology. 


628  MEDICO-LEGAL  PRACTICE. 

point  of  view,  the  piincipal  points  in  legal  medicine 
of  insanity  that  are  likely  to  interest  practitioners 
and  magistrates  as  well  as  specialists  themselves. 

The  legal  medicine  of  insanity  divides  itself 
naturally  into  two  parts,  corresponding  to  the  two 
great  divisions  of  the  law:  (1)  the  part  relative  to 
the  criminal  law ;  (2)  the  part  relative  to  the  civil  law. 

The  first  two  chapters  which  follow  are  devoted  to 
the  study  of  the  more  important  questions  of  crim- 
inal legal  medicine,  the  third  and  last  chapters  to 
those  relating  to  civil  law. 


Note.— This  chapter  on  the  Civil  Code,  referring  as  it  does  exclu- 
sitely  to  Fz'ench  law  and  practice,  as  well  as  a  former  chapter  ou  the 
French  law  of  commitment  for  insanity  are  omitted,  by  permission 
of  the  author,  from  this  translation. 


Cbapter  fivet 

CRIMINAL   CODE. 

I.— PENAL  RESPONSIBILITY  OF   THE  INSANE.  ' 
II.— CRLMES  AND  MISDEMEANORS  OF  THE  INSANE. 


I. — Penal  Responsibility  of   the  Insane. 

Absolute  Irresponsibility.  Partial  Respons- 
ibility.— Every  crime  or  misdemeanor  is  composed, 
says  the  legislator,  of  the  act  and  the  intention,  but 
no  criminal  intent  can  exist  in  an  accused  person  who 
has  not  the  exercise  of  his  moral  faculties;  and 
freedom  from  penalty  of  the  law  should  be  granted 
any  man  when  disease  has  enervated  his  intelligence, 
obscured  his  judgment,  perverted  his  conscience, 
disordered  his  reason,  and  deprived  him  of  his  free 
will.  A  single  article  of  the  Penal  Code  (French)  lays 
down  in  unmistakable  and  vigorous  language  these 
eternal  principles  of  moral  justice,  and  preserves  the 
lunatic  from  the  rigors  reserved  for  the  criminal. 
Article  64:  '■'■There  is  no  crime  or  misdemeanor 
when  the  accused  was  in  a  state  of  dementia  at  the 
time  of  the  act^  or  when  he  has  been  under  the  com,- 
pulsion  of  a  force  he  was  unable  to  resist.''''  It  is 
not  necessary  to  add  that,  under  the  generic  terra  of 
dementia^  the  law  understands  not  only  the  form  of 


630  MEDICO-LEGAL  PRACTICE. 

mental  derangement  that  bears  that  name,  but  all 
mental  alienation,  whatever  maybe  its  form.  "By 
dementia^'''  say  MM.  Adolphe  Chauveau  and  Faustin 
Helie, "  we  must  understand,  since  no  text  has  limited 
its  meaning,  all  the  diseases  of  the  intellect,  idiocy 
and  dementia,  properly  so-called,  delusional  mania 
and  mania  ^^ithout  delusions  (that  is  affective  mania), 
even  when  partial.  All  the  varieties  of  mental 
disease,  whatever  the  name  science  may  apply  to 
them,  whatever  their  classification,  carry  with  them 
the  power  of  excusing  the  act,  and  acquit  the  ac- 
cused, provided  that  their  influence  on  the  act  can  be 
presumed." 

The  French  law,  therefore,  absolves  the  lunatic 
from  responsibility  for  his  actions.  All  legisla- 
tion, moreover,  since  the  morbid  nature  of  insanity 
has  been  recognized,  has  admitted  the  criminal 
irresponsibility  of  the  insane,  and  it  is,  therefore, 
needless  to  discuss  here  the  great  principle  of  human 
freedom  and  the  conditions  of  the  loss  of  free  will  in 
beings  deprived  of  reason.  We  must,  nevertheless, 
notice  the  disagreement  of  late  years  relative  to  the 
degree  of  responsibility  in  some  forms  of  mental  de- 
rangement :  many  authorities  admitting,  with  M.  Le- 
grand  du  SauUe,  that  if  certain  of  the  insane  are  com- 
pletely irresponsible  for  their  acts,  others  are  only  so 
in  part,  whence  the  names  of  partial^  proportional^ 
and  attenuated  responsibility  given  to  this  latter  con- 
dition ;  other  authorities  maintain  vigorously,  on  the 
contrary,  with  M.  J.  Falret,  the  absolute  principle 


RESPONSIBILITY  OF  THE  INSANE.  631 

of  entire  irresponsiliility  in  insanity,  whatever  may 
be  its  form. 

The  arguments  presented  by  these  last  and  espe- 
cially those  of  M.  J.  Falret,  who  has  supported  his 
opinion  with  rare  talent,  seem  to  me  to  settle  the 
question  and  to  clearly  establish  that  in  law  as  in  fact, 
every  individual  aifected  with  confirmed  mental  de- 
rangement, is  on  that  account,  irresponsible.  Beyond 
the  fact  that  this  doctrine,  as  just  as  it  is  positive, 
closes  the  door  to  all  quantitative  and  individual 
valuations  of  moral  capacity,  and  consequently  to 
those  psychological  subtilties  that  deserve  no  place  in 
legal  medicine,  it  has  still  the  immense  advantage 
of  substituting  for  those  arbitrary  and  contra- 
dictory elements  of  appreciation,  such  as  those  based 
on  the  degree  of  knowledge  of  right  or  wrong,  on 
the  pathological  nature  or  otherwise  of  the  act,  a 
positive  criterion,  entirely  medical  in  character, 
namely,  the  existence  or  non-existence  of  mental 
derangement.  With  this  principle  of  total  irrespons- 
ibility, everything  is  reduced,  in  fact,  to  ascertain- 
ing whether  or  not  there  is  insanity,  and  not  to 
measuring  the  degree  of  discernment  and  conscious 
responsibility  of  a  patient. 

But  if  the  doctrine  of  attenuated  responsibility 
cannot  be  admitted  in  any  case  of  well  marked  insanity, 
properly  so-called,  we  often  find  its  application,  on 
the  other  hand,  in  certain  cases  of  semi -alienation, 
where  the  responsibility  for  acts,  although  persisting 
in  different  degrees,  is  nevertheless  manifestly  dim- 


^32  MEDICO-LEGAL  PRACTICE. 

inished.  The  most  convinced  partisans,  moreover, 
of  the  absolute  irresponsibility  of  the  insane,  have 
themselves  admitted  in  formal  terms  partial  respons- 
ibility in  certain  pathological  conditions,  and  M.  J. 
Falret  himself  says  in  this  regard:  "  But  if  we  do 
not  admit  the  partial  responsibility  of  the  insane,  thus 
understood,  that  is  to  say,  as  regards  certain  things 
and  not  in  others  at  the  same  time^  we  are  all  dis- 
posed to  admit  it  at  different  times.  We  are  all 
compelled  to  say  that  there  are  moments  in  the  life 
of  individuals  in  which  we  must  admit  either  their 
entire  responsibility,  as  in  the  periods  of  predispo- 
sition, intermissions,  or  lucid  intervals,  or  their 
incomplete  or  lessened  responsibility,  as  in  the  periods 
of  incubation,  of  more  or  less  complete  remission,  or 
of  convalescence.  We  admit  also  that  the  question 
of  complete  or  incomplete  responsibility  may  be  dis- 
cussed in  certain  states  of  mental  disorder  apart  from 
insanity,  properly  speaking,  such  as  apoplectic 
dementia  and  aphasia,  hysteria,  epilepsy,  and  alcohol- 
ism. It  is  within  these  narrow  limits,  apart  from 
mental  alienation  or  confirmed  insanity  that  we 
admit  partial,  incomplete,  or  attenuated  respons- 
ibility." 

The  principal  morbid  conditions  in  which  M. 
Falret  admits  this  graduation  of  penal  responsibility, 
are  the  following : 

1.  The  first  stages  of    mental  disease;  the    pro- 
dromic  period  or  stage  of  incubation ; 

2.  Apoplectic  dementia  and  aphasia; 


EESPONSIBELITY  OF  THE  INSANE.  633 

3.  The  conditions  of  lucid  interval,  of  intermission, 
and  of  remission ; 

4.  The  periods  of  predisposition  to  insanity ; 

5.  Hysteria,  to  which  may  be  added  somnambu- 
lism and  hypnotism; 

6.  Epilepsy; 

7.  Alcoholism; 

8.  Conditions  of  imbecility  or  natural  mental 
weakness. 

"These,"  says M.  Falret, "  are  mixed  states,  inter- 
mediate between  reason  and  insanity,  and  in  which 
it  is  permissible  to  discuss  the  degree  of  respons- 
ibility, to  admit  entire  responsibility  or  attenuated 
responsibility,  according  to  the  case,  and  in  which 
there  is  no  room  to  apply  the  criterion  of  absolute 
irresponsibility,  which,  for  our  part,  we  recognize  in 
all  cases  of  really  confirmed  or  clearly  character- 
ized mental  alienation." 

It  seems  to  us  difficult  not  to  agree  with  the 
opinion  so  clearly  stated  by  M.  Falret,  and  not  to 
admit,  with  him,  that,  in  cases  of  pronounced 
mental  alienation,  there  can  be  no  question  as  to  the 
absolute  irresponsibility,  partial  responsibility  being 
reserved  for  those  conditions  of  mental  disorder 
that  hold  a  place  midway  between  reason  and 
insanitv. 

It  will  be  understood  that  it  is  impossible  to 
discuss  here  successivel}'^  the  degree  of  responsibil- 
ity appertaining  to  the  different  states  of  semi- 
alienation  of  which  we  speak,  not  merely  because 


634  MEDICO-LEGAL  PRACTICE. 

the  question  allows  of  excessive  amplification,  but  also 
because  we  cannot  lay  down  any  general  rules  appli- 
cable to  all  cases,  and  that  it  is  before  all  necessary  to 
judge  from  particular  facts.  We  must  not  forget  that 
partial  responsibility  is  delicate  ground,  a  sort  of  com- 
promise between  science  and  justice,  as  M.  Lutaud 
says,  and  that  consequently  the  physician  should  use 
this  implement  only  with  reserve,  if  he  wishes  to  ex- 
tract from  it  all  the  good  of  which  it  is  capable.* 
We  will  say  only  a  word  on  the  degree  of  respons- 
ibility in  remissions,  intermissions,  and  lucid  inter- 
vals. 

Responsibility  in  the  Conditions  of  Remission, 
Intermission,  and  Lucid  Intervals. — In  the  states 
of  remission,  which  form,  as  we  have  seen,  an  atten- 
uation of  the  symptoms  of  the  mental  disease,  the 
degree  of  penal  responsibility  may  be  discussed. 
But,  as  M.  J.  Falret  says,  the  legal  question  is 
hard  to  decide  in  these  cases.  "Here,  indeed,  doubt 
is  permissible,  the  question  to  be  solved  becomes  one 
of  degree,  and,  in  consequence,  the  answer  cannot  be 
absolute;  it  cannot  be  formulated  by  regular  rules 
and  necessarily  depends  upon  each  particular  case." 
In  these  cases  the  most  resolute  partisans  of  abso- 
lute irresponsibility  can  admit  an  attenuation  of  the 

*We  would  refer  more  particularly,  for  the  study  of  the  questions 
of  responsibility  and  capacity  in  the  mixed  conditions  to  the  works 
of  Charcot,  Legrrand  du  Saulle,  Huchard,  Pitres,  Colin,  on  Hysteria ; 
to  those  of  Christian  and  F6r6  on  Epilepsy ;  to  those  of  Motet  and 
Vctault  on  Alcoholism ;  and  to  those  of  Liegeois,  Charcot,  Brouardcl, 
Pitres,  Bemhcim,  Gilles  de  la  Tourette,  B(irillon,  etc,  on  Somnam- 
bulism and  Hypnotism. 


EESPONSIBILITY  OF  THE  INSANE.  635 

responsibility  proportional  to  the  intensity  of  the 
disease  or  the  remission.  But  as  I  have  already  said 
many  times,  this  responsibility  is  not  partial  and 
complete  at  the  same  time ;  it  does  not  exist  for 
certain  acts  while  it  is  suppressed  for  certain  others ; 
it  is  variable  according  to  the  times  and  not  at  the 
same  instant;  it  is  absent  during  the  attacks  and  may 
be  considered  as  complete  or  as  simply  attenuated 
during  the  periods  of  remission,  which  can  be  de- 
termined and  pronounced  by  the  clinical  physician. 
The  study  of  these  remissions  and  their  degrees,  in 
the  different  forms  and  periods  of  mental  derange- 
ment, is  one  of  the  most  interesting  subjects  in  the 
legal  medicine  of  insanity ;  but  this  chapter  is  yet  to 
be  written  in  a  clinical  and  scientific  point  of  view. 
This  study  has  been  chiefly  made  in  regard  to  the 
remissions  of  general  paralysis  (Baillarger,  Sauze, 
Legrand  du  Saulle,  Doutrebente). 

As  regards  intermittences  or  intermissions,  that  is, 
the  complete  return  to  reason  between  two  attacks 
of  insanity,  such  as  occurs  in  intermittent  mania, 
double  form  insanity,  etc.,  the  question  of  responsi- 
bility appears  under  another  form,  since  here  we  no 
longer  have  to  do  with  a  simple  amelioration,  the 
degree  of  which  is  to  be  estimated,  as  is  the  case  in 
the  remission,  but  with  a  veritable  return  to  the  nor- 
mal condition.  "But,"  says M.  Falret,  "  in  these  so 
frequent  cases,  which  are  met  with  as  well  in  the 
melancholiac  as  in  the  maniacal  forms,  the  question 
of  responsibility  offers  itself  naturally  in  all  its  dis- 


636  MEDICO-LEGAL  PEACTICE. 

tinctness  and  all  its  rigor.  A  true  intermission  is, 
in  reality,  a  temporary  or  momentary  recovery. 
We  ought,  therefore,  to  apply  to  it  the  same  rule 
as  to  recovery,  i.  e.,  to  consider  the  individual  in 
this  condition  as  possessing  all  his  faculties,  and  there- 
fore his  full  penal  responsibility  and  civil  capacity. 
The  only  difficulty  in  these  cases  (and  it  is  often  a 
ver}''  serious  one)  is  a  clinical  difficulty,  a  question 
of  diagnosis.  The  expert  has  to  show  by  positive 
proofs  that  the  individual  examined  was  sound  of 
mind  at  the  time  of  the  act,  in  a  true  period  of  inter- 
mission, in  a  real  and  not  merely  an  apparent  re- 
covery, and  not  in  a  state  of  simple  remission,  more 
or  less  marked,  or  in  a  state  of  voluntary  conceal- 
ment of  delusions  such  as  often  occurs,  for  example, 
in  the  remissions  of  insanity  of  persecution.  This 
clinical  problem  is  often  very  hard  to  solve,  and  is 
one  of  the  most  delicate  points  in  the  legal  medicine 
of  insanity.  But,  in  principle,  we  cannot  deny 
that  true  periods  of  intermission  often  occur  in 
mental  disorders,  and  that  during  these  periods  the 
individual  should  be  considered  as  having  recovered 
his  moral  responsibility  and  his  civil  capacity." 
This  is  also  the  opinion  of  most  authors,  and  of 
M.  Doutrebente  in  particular,  who  says  himself,  in 
this  regard :  "From  all  that  precedes  it  is  easy  to  con- 
clude that  during  the  intermission  the  intermittent 
lunatic  can  and  should  be  likened  to  a  recovered 
patient  or  to  a  man  of  sound  mind,  and  that  conse- 
quently he  is  in  possession  of  his  civil  capacity  and  is 


CEIMES  AND  MISDEMEANORS  OF  THE  INSANE.     637 

responsible  for  his  actions ;  we  will  nevertheless,  make 
some  reservations  in  the  case  of  intermissions  of 
short  duration  alternating  with  frequent  attacks  of 
mental  derangement,  since,  in  these  cases,  the  inter- 
mission approaches  closel}^  to  simple  lucid  moments." 

This  last  restriction  of  M.  Doutrebente  can  be 
applied,  for  example,  to  double  form  insanity  of 
short  attacks,  separated  from  each  other  only  by  an 
interval    of    a  day  or  a  few  dsijs  of  intermission. 

The  question  is  quite  diiferent  as  regards  lucid 
moments,  since,  in  these  cases  we  have  solely  to  do 
with  a  complete  but  altogether  temporary  suspension 
of  the  symptoms  of  the  disease,  in  the  course  of  the 
same  attack.  Here  the  lucidity  has,  so  to  speak, 
only  the  duration  of  a  flash  of  lightning  and  the 
usual  irresponsibility  of  the  patient  may  be  con- 
sequently considered  as  not  being  suspended.* 

II. — Crimes  and  Misdemeanoes  of  the  Insane. 

We  do  not  pretend  to  give  here  any  complete  study 
of  the  crimes  and  misdemeanors  of  the  insane.  We 
desire  only,  in  enumerating  the  chief  of  them,  to  indi- 
cate their  general  characters  and  their  special  char- 
acteristics in  each  of  the  great  forms  of  mental 
alienation. 

A. — General  Characters. — All  the  crimes  and 
all  the  misdemeanors,  of  whatever  kind,  may  be  met 

♦One  may  also  consult  with  benefit,  on  this  subject,  the  work  of  Max 
Simon:    Cinmes  and  Misdemeanors  in  Insanity,    1886. 


638  MEDICO-LEGAL  PRACTICE. 

with  in  mental  alienation,  in  such  a  way  that,  as 
regards  their  nature  itself,  they  differ  in  no  respect 
from  any  others.  The  most  frequent,  however,  are : 
homicide  and  attempts  at  homicide,  criminal  assault 
and  rape,  thefts,  arson,  forgery,  slander,  libel,  simu- 
lation, etc.,  etc. 

In  certain  cases  the  act  itself  and  the  circumstances 
accompanying  it,  bear  the  manifest  stamp  of  the  state 
of  derangement  of  the  individual  who  has  committed 
it.  Thus  certain  homicides  or  attempts  at  homicide 
are  committed  by  lunatics  in  a  condition  of  delirious 
agitation  and  maniacal  fury  that  leave  no  doubt  as  to 
their  mental  condition.  At  other  times  they  are  the 
result  of  a  sudden,  instantaneous  impulse,  the  violence 
and  unexpectedness  of  which  are  sufficient  to  reveal 
their  pathological  nature.  Frequently  also,  the  mis- 
demeanor, criminal  assault  or  theft  is  so  silly,  ridicu- 
lous, and  witless,  that  it  bears  in  itself  the  mark  of 
dementia.  Or  the  lunatic  takes  no  precaution  to 
conceal  it,  and  seems  to  choose  fgr  the  accomplish- 
ment of  his  project  a  moment  when  he  cannot  fail  to 
be  caught.  In  other  cases  again,  he  may  denounce 
himself,  boasting  of  his  crime  or  misdemeanor  as  if 
it  were  a  perfectly  natural  or  even  a  meritorious 
thing.  In  some  cases  he  will  completely  forget  the 
fact  and  have  no  recollection  of  his  act.  Finally,  the 
crime  may  have  no  semblance  of  an  end  or  excuse, 
as  when  a  lunatic  all  at  once  attacks  in  the  street 
some  one  whom  he  does  not  know,  or  steals  some 
article  of  no  possible  utility  to  him. 


CRIMES  AISTD  MISDEMEANORS  OF  THE  INSANE.    639 

But  if  the  crimes  and  misdeeds  that  have  the  in- 
sane as  their  authors  carry  sometimes  the  special 
characters  of  their  diseased  origin,  this  is  far  from 
being  always  the  case.  Indeed,  some  of  the  insane 
act  from  perfectly  determined  motives,  prepare  and 
plan  their  misdoings  long  beforehand  with  a  patience, 
a  fixedness  of  purpose,  an  address,  a  consecutiveness, 
a  talent  for  combination,  and  an  amount  of  precau- 
tion, ruses,  and  calculations  that  might  deceive  the 
most  skilful  and  clearsighted.  Sometimes  even,  like 
the  true  criminals,  they  may  deny  the  commission 
of  the  act  or  give  it  an  appearance  of  reasonableness, 
explaining  it  by  plausible  and  almost  sensible  mo- 
tives. Nothing  therefore  is  more  incorrect  than  the 
notion,  held  by  the  majority  of  the  public,  that  the 
criminal  and  unlawful  acts  of  the  insane  are  always 
characterized  by  want  of  foresight  and  the  greatest 
spontaneity  and  absurdity.  There  are  cases,  on  the 
other  hand,  where  nothing  at  first  sight  betrays  the 
morbid  nature  of  the  criminal  act,  and  this  is  why 
the  medico-legal  valuation  of  certain  acts  is  often  so 
difficult  to  fix. 

B. — Particular  Characters  in  the  Principal 
Morbid  Forms. — One  very  important  element  of  the 
inquiry  is  found  in  certain  special  characters  which 
the  crimes  and  misdemeanors  of  the  insane  borrow, 
not  only  from  their  pathological  nature,  but  also 
from  the  form  itself  of  the  disorder  in  which  they  are 
observed. 


640  mi:dico-legal  peactice. 

We  have  already,  in  discussing  the  reasons  that 
may  necessitate  sequestration,  stated  in  the  preceding 
pages  the  principal  characters  of  the  morbid  acts  in 
the  great  varieties  of  mental  alienation,  laying  espe- 
cial stress  on  those  acts  that  most  frequently  caused 
the  patients  to  be  dangerous.  "We  will  therefore 
content  ourselves  here  with  pointing  out  certain  pe- 
culiarities relating  to  those  acts  that  may  constitute 
in  legal  medicine  an  indication  of  some  value. 

Degeneracies. — The  degenerates,  from  the  sim- 
ple neurastheniacs  with  obsessions  to  the  imbeciles 
and  idiots,  are,  above  all,  subjects  of  impulse,  on  ac- 
count of  their  greater  or  less  feebleness  of  will. 
In  the  higher  degenerates,  as  Magnan  calls  them 
(ill-balanced,  neurastheniacs,  phrenastheniacs) ,  there 
is  still  resistance  and  consciousness;  in  the  inferior 
degenerates,  the  act  becomes  instinctive  and,  so  to 
speak,  automatic,  it  approaches  a  reflex. 

The  more  common  impulsions  in  neurasthenias  are 
those  to  drink,  arson,  murder,  theft,  suicide,  and 
sexual  aberrations  of  every  kind  (hair  cutters,  col- 
lectors of  female  objects,  rubbers,  exhibitionists, 
platonic  lovers,  etc.)  These  impulsions  take  the 
character  of  emotional  and  conscious  obsessions,  and 
it  is  only  after  a  more  or  less  lively  resistance  that 
the  patient  finally  gives  way  to  them. 

In  the  delusional  and  reasoning  phrenasthenias  the 
dominant  morbid  tendencies  are,  on  the  one  hand,  the 
tendency  to  private  murder  (reasoning  persecutory 


CRIMES  AND  MISDEMEANOES  OF  THE  ES-SANE.    641 

insanity),  to  religious  or  political  murder  (regicides), 
and  on  the  other  to  moral  perversion.  Nowhere  is 
the  conception  of  the  act  more  clear,  more  calculated, 
more  logical  in  appearance  and  more  premeditated 
than  in  this  class  of  patients.  Those  more  particu- 
larly affected  with  moral  perversion,  the  morally 
insane  as  we  call  them,  rarely  attempt  a  criminal  act; 
they  are  dangerous  rather  to  the  reputation  and  honor 
of  individuals,  since  the}^  use  falsehood,  dissimulation, 
and  calumny  with  a  consummate  art,  and  there  is 
nothing,  in  this  line,  that  they  will  not  invent  to 
injure  those  who  have  gained  their  ill  will.  It  is  in 
regard  to  these  that  the  medico-legal  question  presents 
perhaps  the  greatest  difficulties,  as  the  absence  of 
delusion  on  the  one  hand,  and  the  incredible  skill 
with  which  they  have  framed  their  j)lots  on  the  other, 
render  the  estimation  of  their  mental  condition  a  very 
delicate  matter,  and  make  the  excuse  of  insanity  very 
difficult  of  acceptation  by  the  judges.  To  these 
patients  it  is  necessary  to  compare  the  double  form 
lunatics,  and  especially  the  subjects  of  hysteria,  who 
resemble  them  closely  in  that  their  insanity  is  very 
frequently  manifested  under  the  reasoning  form. 

Special  mention  should  be  made  of  the  instinctive 
phrenasthenias,  which  constitute  what  we  call  the 
ermiinal  psychosis,  and  in  which  should  be  ranked 
the  born  ci'iminals  of  Lombroso.  All  crimes  and 
misdemeanors  are  met  with  in  this  class.  The  char- 
acters of  the  born  criminals,  in  both  a  physical  and  a 
psychical   point   of   view,    have   been   many  times 


642  MEDICO-LEGAL  PRACTICE. 

pointed  out  by  Lombroso  and  his  disciples,  but,  as 
we  have  said,  they  are  in  no  way  absokitely  specific 
and  do  not  materially  differ  from  the  other  characters 
and  stigmata  of  degeneracy.* 

In  the  states  of  mental  weakness,  properly  speaking, 
either  congenital  or  acquired  (imbecility,  idiocy, 
dementia),  the  criminal  or  unlawful  act,  is  usually 
puerile,  unconscious,  absurd,  sometimes  automatic. 
Murder  is  rather  rare,  at  least  when  native  infirmity 
of  the  intelligence  is  uncomplicated  with  any  neuroses 
or  acute  attack  of  insanity.  It  is  with  offenses 
against  decency,  rape,  and  thefts  that  we  have  to  do 
with  in  these  cases.  The  indecent  acts  of  these  weak- 
minded  patients  may  be  the  result  of  a  greater  or 
less  degree  of  genesic  excitement,  in  which  case  they 
bear  the  stamp  of  this  super-excitation,  and  some- 
times even  of  bestial  violence,  but  more  often  still 
they  are  silly,  absurd,  and  purposeless.  It  is,  in 
fact,  among  these  patients  that  are  principally  to  be 
found  the  exhibitiooiists  of  Lasegue,  i.  e.,  patients 
who,  without  knowing  why  they  do  so,  content  them- 
selves with  displaying  their  genital  organs  in  public. 

After  offenses  against  decency,  come  thefts,  more 
frequent  in  dementia  and  absurd  as  in  general  paral- 
ysis ;  lastly,  we  may  observe  arson,  especially  among 
imbeciles. 

Maniacal  Conditions. — Crimes  and  misdemean- 
ors are  rare  in  mania,  although  this  is  the  form  of 


*  See  Corre,  les  Criminels,  (1889) ;  Dortel,  V  Anthropologie  Criminelle  et 
la  Bespomabilite  Medico-legale,  {These,  Paris,  1891). 


CRIMES  AND  MISDEMEANORS  OF  THE  INSANE.    643 

insanity  that  seems  most  terrifying ;  this  is  because 
the  patients  are  absolutely  incapable  of  conceiving 
any  act  whatever,  and  they  are  rather  destructive 
than  really  dangerous.  Nevertheless,  when  the  agit- 
ation is  pushed  to  paroxysms  of  fury,  it  may  be  the 
cause  of  a  homicide,  accomplished  under  conditions 
of  violence  and  hyper-excitement  that  leave  no  doubt 
as  to  their  true  character. 

Melancholic  States. — Crimes  and  misdemeanors 
are  rare  in  states  of  melancholia,  where  we  observe 
almost  exclusively,  as  we  have  stated,  the  tendency 
to  suicide.  ISTevertheless,  homicide  may  be  seen  in 
exceptional  cases  of  certain  forms  of  acute  lype- 
mania,  but  then,  far  from  having  hatred  or  malice 
for  its  motive,  it  results  nearly  always,  on  the  con- 
trary, from  an  excess  of  affection  or  a  deluded  sym- 
pathy for  the  victim.  Thus,  I  have  seen  at  Sainte- 
Anne  a  woman  in  a  condition  of  acute  melancholia 
who,  when  she  threw  herself  into  the  river  with 
suicidal  intent,  took  with  her  her  two  young  children, 
so  as  not  to  leave  them  on  earth  exposed  to  the  mis- 
eries of  existence.  In  this  case  we  might  almost  say 
that  the  insane  person  commits  the  suicide  of  other 
individuals,  as  with  herself,  in  order  to  protect  them 
from  the  torments  and  punishments  which,  she  thinks, 
threaten  them  also.  We  may  also  see  in  melancholia 
indirect  suicide,  that  is  to  say,  an  act  of  homicide 
committed  for  the  purpose  of  bringing  about  the 
death  of  the^  one  committing  it,  either  on  account  of 


644  MEDICO-LEGAL  PRACTICE. 

dread  of  killing  himself,  or  in  order  that  he  may  have 
time  for  repentance. 

Partial  or  Systematized  Insanities. — In  the 
systematized  insanities,  homicide  is  the  leading 
offense,  and  we  may  say  that  it  is  most  frequent  in 
this  type  of  mental  disorder. 

The  deluded  mystics,  as  we  have  seen,  often 
believe  they  have  received  a  commission  from  heaven 
to  kill  some  more  or  less  prominent  personage,  who 
they  think  represents  the  cause  hostile  to  God  on 
earth,  and  then  they  coolly,  with  calculation  and 
premeditation,  assassinate  that  individual ;  more  fre- 
quently they  immolate  in  sacrifice  their  own  children ; 
or  even  the  first  persons  they  meet,  persuaded  that 
in  so  doing  they  are  in  some  way  pleasing  the  Deity. 
Their  prophetic  and  inspired  attitudes,  their  delusions, 
and  even  the  circumstances  of  their  act  are  enough, 
as  a  rule,  to  cause  the  recognition  of  their  insanity, 
although  their  apparent  lucidity,  and  the  calmness 
and  the  reticence  behind  which  they  intrench  them- 
selves, sometimes  make  the  forming  of  an  opinion 
somewhat  difficult. 

The  subjects  of  persecutory  delusions,  as  we  have 
not  ceased  to  reiterate,  are,  of  all  the  insane,  the 
most  dangx?rous.  With  them,  homicide  is  chiefly  to 
be  feared ;  because,  believing  themselves  the  butt  of 
their  imaginary  persecutions  and  considering  them- 
selves the  victims  of  an  organized  conspiracy  into 
which   enter  a  more   or  less    considerable    number 


CRIMES  AND  MISDEMEANORS  OF  THE  INSANE.     645 

of  persons,  they  finally    come  to  act,   against  their 
supposed  enemies,  as  persecutors  and  as  aggressors. 

There  are  in  this  respect,  two  great  classes  of 
patients.  The  first,  the  most  numerous  class,  base 
their  ideas  of  persecution  on  various  sensory  disturb- 
ances, and  especially  on  hallucinations  of  hearing, 
which  become  the  fundamental  element  of  their  ex- 
istence, and  finish  in  directing  and  misleading  them 
more  and  more  into  their  delusions.  These  are  the 
hallucinated  persecutory  cases.  The  others,  appar- 
ently rational,  build  up  on  some  more  or  less  salient 
circumstances  of  their  lives  a  whole  system  of  per- 
fectly coherent  delusive  conceptions,  based  on  a 
semblance  of  truth,  and  which,  defended  wath  as 
much  skill  as  conviction,  are  almost  invariably  very 
logically  combined.  These  patients,  usually  free 
from  hallucinations,  and  more  partially  affected  in 
their  faculties,  are  the  reasoning  persecutory  cases. 
They  fall  into  the  category  of  the  degenerates. 

Whether  hallucinated  or  reasoning,  these  persecu- 
tory cases  are,  we  cannot  too  often  repeat,  the  most 
dangerous  of  the  insane,  and  a  large  portion  of  all 
pathological  crimes  can  certainly  be  attributed  to 
them.  Still  more,  perhaps,  than  the  hallucinated 
cases,  who  kill  chiefly  from  an  impulsion,  under  the 
influence  of  an  hallucination  or  under  that  of  a 
transitory  exaltation,  the  persecuted  degenerates  are 
to  be  feared,  and  this  because  they  reason  out  their 
delusion  and  carry  out  in  cold  blood,  so  to  speak, 
the  crime  they  have  conceived.     It  is  a  curious  fact, 


646  ilEDICO-LEGAL  PRACTICE. 

nevertheless,  and  one  that  seriously  complicates  the 
r6le  of  the  medical  expert  before  the  courts,  that  it 
is  just  these  patients,  the  worst  of  all  without  any 
dispute,  whom  it  is  most  difficult  to  make  accepted 
as  such  by  the  magistrates  and  by  the  public. 

Persecutory  cases,  moreover,  do  not  confine  them- 
selves to  merely  attacking  their  enemies,  sometimes 
their  victims  are  those  they  have  never  before  seen ; 
they  may  also,  though  much  more  rarely,  commit  rape 
or  arson. 

HEBEPHREisriA. — In  hebephrenia,  and  in  a  general 
way,  in  all  the  disorders  of  intelligence  that  mani- 
fest themselves  in  childi'en,  the  criminal  or  unlawful 
acts  assume  generally  the  character  of  a  sudden, 
instantaneous  and  unreflecting  impulse.  There  are 
motiveless  murders  committed  often  under  circum- 
stances of  astonishing  cruelty  and  ferocity,  thefts, 
and  incendiarism.  It  is  rare  in  these  cases  that  the 
precocity  itself  of  the  criminal,  added  to  the  impul- 
sive nature  of  the  act,  the  lack  of  thought,  and  the 
cruelty  of  which  it  gives  proof,  do  not  put  one 
readily  on  the  track  of  his  real  condition. 

Puerperal  Insaitity. — In  puerperal  insanity  the 
most  frequent  crimes  and  misdemeanors  are  theft 
and  homicide :  the  theft  under  the  form  of  an  impul- 
sion, a  sudden  instigation,  a  desire  to  satisfy,  chiefly 
in  ante  partum  insanity;  the  homicide,  and  more 
especially  infanticide,  also  under  the  form  of  an 
impulsion,  chiefly  ui  post  partum  insanity  and,  more 
yet,  in  the  insanity  of  childbed,  properly  so-called. 


CBIMES  AND  MISDEMEANORS  OF  THE  INSANE.    647 

In  the  latter  case  it  is  sometimes  very  difficult 
to  appreciate  the  pathological  nature  of  the 
act,  the  more  so  from  the  fact  that  childbed 
insanity  may  be  absolutely  transitory,  not  lasting 
beyond  a  few  hours  or  a  few  days. 

Toxic  Insanities. — In  the  toxic  insanities,  and 
particularly  in  alcoholic  insanity,  the  form  most 
often  in  question  in  a  medico-legal  way,  suicide 
dominates  as  a  morbid  tendency,  at  least  in  the  sub- 
acute form.  In  the  acute  form,  on  the  contrary, 
homicide  is  not  uncommon,  and  the  patients  im- 
pelled by  their  terrors  and  their  agitation  throw  them- 
selves upon  their  victims  whom  they  butcher  with  an 
indescribable  fury.  They  resemble  in  this  point  of 
view  maniacs  and  ej)ileptics,  and  their  state  of 
agitation  itself,  usually  tremulous,  is  commonly  suffi- 
cient to  reveal  the  toxic  influence.  They  may  also, 
either  simultaneously  or  each  by  itself,  commit  arson, 
theft,  or  offenses  against  decency. 

General  Paralysis. — The  prodromic  period  of 
general  paralysis,  when  it  assumes  the  excited  form, 
is  very  often  the  theatre  of  pathological  acts,  among 
which  misdemeanors,  in  the  place  of  crimes,  hold  a 
large  place.  In  this  respect  this  period  has  been 
made  the  subject  of  a  special  study  by  M.  Legrand 
du  Saulle,  under  the  name  of  the  vnedico-legal  period 
of  general  paralysis.  The  most  frequent  mis- 
demeanor is  theft,  next  comes  indecent  behavior, 
lastly  forgery,  breach  of  trust,  and  rarely  homicide 
or  attempt  at  homicide. 


648  MEDICO-LEGAL  PEACTICE. 

Whatever  the  act  committed  may  be  it  presents 
special  characters  which  are  generally  sufficient  to  en- 
able us  to  refer  them  a  priori  to  their  true  origin. 
The  thefts  of  general  paralytics,  which  have  been 
the  subject  of  special  study  and  analysis,  are,  indeed, 
characteristic.  The  paralytic  takes  from  a  store, 
without  precaution  and  with  the  candor  of  innocence 
some  insignificant  object,  such,  for  example,  as  a 
worthless  umbrella,  a  pair  of  shoes,  or  trousers,  a 
bunch  of  cabbage,  an  egg,  or  some  delicacy  of  little 
value.  He  has  no  idea  of  what  to  do  with  the  ob- 
ject stolen,  and  almost  immediately  gives  it  away  for 
charity  to  some  beggar.  He  is  so  unconscious  of  the 
nature  of  his  act  that  he  commits  it  without  conceal- 
ment, before  everybody,  and  often  even  calls  in  the 
help  of  a  stranger  to  help  him  in  his  larceny,  like  the 
paralytic  mentioned  by  M.  Magnan  who,  wishing  to 
carry  off  a  cask  of  wine  called  in  the  aid  of  a  police- 
man, who,  deceived  by  his  candor,  aided  him  to  roll 
his  cask.  The  theft  of  the  paretic,  like  the  other 
crimes  he  commits,  is  an  absurd,  silly  theft,  the  theft 
of  a  demented  person,  since  it  is  clearly  to  his  de- 
mented state  that  is  due  his  action,  as  is  also  the 
equally  absurd  and  silly  character  of  his  delusions. 
It  is  more  than  is  required  for  the  diagnosis  of  even 
incipient  general  paralysis,  and  experts  do  not  usually 
hesitate  when  they  have  to  judge  upon  a  theft  com- 
mitted under  these  conditions  by  a  man  of  some  forty 
years  of  age,  even  Avhen  the  physical  signs  of  the 
malady  are  not  yet  very  pronounced. 


CRIMES  AND  MISDEMEANORS  OF  THE  INSANE.    649 

Epilepsy. — With  the  cases  of  dehisions  of  perse- 
cution, it  is  epilepsy  that  furnishes  the  largest  con- 
tingent pathological  crimes  and  misdemeanors. 
The  special  character  that  these  acts  borrow  from 
the  great  neurosis  to  which  they  are  due,  have  been 
thoroughly  studied  and  shown  during  late  years. 
These  characters,  moreover,  are  so  distinct  that  they 
make  it  possible  to  refer  the  act  committed  to  epilepsy, 
even  when  the  outward  signs  of  this  disorder  and 
particularly  the  convulsive  attacks,  are  wanting,  as 
in  case  of  larvated  epilepsy,  epileptic  vertigoes,  and 
petit  tnal.  These  distinctive  peculiarities  consist 
chiefly  in  the  fact  that  the  act  of  the  epileptic,  which 
is  generally  a  crime,  especially  murder  or  incendiarism, 
is  committed  under  the  form  of  a  sudden,  instan- 
taneous, violent  impulsion,  frequently  reproducing 
itself  at  more  or  less  regular  intervals,  and  of  which 
the  patient  retains  no  recollection  after  the  attack. 
This  profound  amnesia  that  makes  the  assassin  or 
the  incendiary  remember  absolutely  nothing  of  what 
is  passed  and  of  what  he  has  done,  is  peculiar  to 
epilepsy  and  is  met  with  under  the  same  characters 
in  no  other  condition.  It  is  often  possible  for  expe- 
rienced physicians,  in  the  presence  of  an  act  of  this 
kind,  not  only  to  recognize  its  pathological  nature, 
but  also  to  make  it  the  starting  point  of  a  complete 
diagnosis,  and  to  suspect  a  hitherto  ignored  epilepsy, 
which  in  fact  reveals  itself  after  a  longer  or  shorter 
period. 

Ment.  Med.— 41. 


Cbapter  n. 

CRBIINAL   CODE  (Continued). 


IVIEDICO-LEGAL  EXMnNATIOXS. 

We  have  laid  down  in  the  preceding  chapter  the 
principle  of  the  irresponsibility  of  the  insane,  and 
shown  the  nature  and  character  of  the  more  frequent 
crimes  and  misdemeanors  in  mental  alienation  in 
general,  and  in  each  of  its  principal  types,  in  particu- 
lar. It  now  remains,  in  concluding  the  subject  of  the 
criminal  portion  of  legal  medicine,  to  state  briefly 
the  role  of  the  physician  when  he  is  intrusted  with 
a  medico-legal  examination  relating  to  insanity. 

This  role  has  been  fully  described  by  numerous 
authors,  notabty  by  my  eminent  and  lamented  rela- 
tive, Dr.  Linas,  in  his  article  in  the '  Dictionnaire 
encyclopedique^  from  which  I  borrow  the  chief 
paragraphs  that  follow. 

Definition  OF  Expertise*  {V  JE)xpertise) . — When, 
in  a  civil  or  a  criminal  suit,  the  question  of  dementia 
is  raised,  men  of  skill  are  usually  called  in,  either  by 

*  The  French  term  ca;;?er<ise  has  no  exact  Enjjlish  equivalent  in  the 
sense  in  which  it  is  here  employed.  I  have  therefore  used  the  word 
as  an  English  one  to  avoid  an  awkward  circumlocution  that  could 
not  moreover  well  express  its  meaning,  which  is  literally  "a  survey 
by  a  board  of  skilled  examiners,"— Tbanslatob, 


DEmnTION  OF  EXPERTISE.  Gol 

the  judges  or  by  the  parties,  sometimes  to  confirm, 
sometimes  to  refute,  the  presumption  or  allegation 
of  insanity.  If  the  physician  acts  by  virtue  of  a 
delegation  of  judicial  authority,  he  properly  takes 
the  title  of  expert;  if  his  employment,  instead  of 
being  by  the  court,  is  friendly  and  at  the  instance 
of  the  parties,  he  is  a  simple  eraploj^e,  not  subject 
to  the  rules  of  the  code  of  procedure.  In  the  first 
case,  the  written  result  of  his  investigations  is  called 
a  report ;  in  the  second  case,  a  consultation.  Which- 
ever way  it  is,  at  base  the  mission  is  the  same, 
though  different  in  origin ;  it  tends  to  the  same  end, 
and  imposes  the  same  duties.  What  applies  to  one, 
applies  also  to  the  other  in  what  we  are  about  to  say. 

First,  what  is  an  expert  examination,  and  what  is 
an  expert  in  the  eyes  of  the  law,  and  in  the  sense  of 
jurisprudence? 

Expcrtisra  is  a  method  of  instruction ;  its  aim  is  to 
enlighten  the  judges  in  difficult,  dubious,  or  obscure 
cases,  and  to  furnish  from  special  knowledge  what 
they  need  in  order  to  solve  the  question  and  make  a 
definite  judgment  possible. 

The  expert  is  a  man  of  skill  charged  with  supply- 
ing these  elements  of  the  judgment. 

In  Prussia,  as  well  as  in  some  other  countries,  the 
laAV  makes  it  a  duty  of  the  court  to  call  in  the  as- 
sistance of  a  medical  legist  to  determine  the  mental 
condition  of  an  individual.  In  France  it  is  optional 
with  the  magistrates  to  order  an  examination  by 
experts,  either  of  his  own  motion  or  on  the  demand 


652  MEDICO-LEGAL  PEACTICE. 

of  the  parties ;  they  are  the  sovereign  judges  as  to 
the  expediency  of  this  measure.  The  obligation  to 
resort  to  experts  is  imposed  upon  the  tribunals  only 
in  certain  special  matters  designated  by  the  law, 
amongst  which  we  regret  not  seeing  mental  alienation 
figure,  as  is  the  case  in  Prussia. 

The  expertise  necessarily  presumes  on  the  part 
of  the  judge,  one  or  several  definite  questions 
addressed  to  the  man  of  skill,  and  on  his  part  an 
answer,  a  personal  and  reasoned  opinion. 

The  role  of  an  expert  in  all  its  simplicity  and 
clearlj'-  defined  is  this :  The  expert  is  less  than  a 
judge;  he  is  more  than  a  mere  witness;  he  differs 
from  the  first  in  that  his  decision  has  in  it  nothing 
imperative,  from  the  second  in  the  extent,  the  import- 
ance, and  the  scientific  character  of  his  testimony. 
In  no  case  should  the  medical  expert  step  out  of  the 
boundaries  of  his  proper  attributes  to  usurp  the  role 
of  an  advocate,  still  less  that  of  a  judge.  He  should 
not  pretend  to  interpret  or  apply  the  law,  and  should 
be  on  his  guard  against  making  dangerous  encroach- 
ments. Fixed  animus  and  vain  declamation  fit  ill  in 
the  mouth  of  a  man  who  should  speak  exclusively  in 
the  name  of  science  and  verity.  His  language  should 
be  severe,  cold,  free  from  any  artifice,  disengaged 
from  all  interests  and  prepossessions.  He  should 
work  for  but  one  end ;  to  instruct  the  conscience  of 
the  judges  and  to  provide  impartial  decisions  for  the 
court. 

In  a  criminal  case,  the  first  and  generally  the  only 


DEFINITION  OF  EXPERTISE.  653 

question  for  the  expert  to  answer  is  this :  Was  the 
accused  in  a  state  of  dementia  or  sound  of  mind 
when  he  committed  the  act  with  which  he  was 
charged? 

Everything  is  therefore  reduced  to  a  question  of 
diagnosis. 

Thus  fixed  on  the  ground  of  pathology  and  of  med- 
ical observation,  the  problem  simplifies  itself,  frees 
itself  from  metaphysical  uncertainties,  and  reduces 
itself  into  two  correlated,  conjoined  and  inseparable 
terms,  which  should  equally  share  the  examination 
of  the  physician ;  the  morbid  state  and  the  subiect, 
that  is  the  fact  and  the  agent,  the  act  and  its  author. 

The  remarks  already  made  relative  to  the  crimes 
and  misdemeanors  of  the  insane  make  it  unnecessary 
to  again  recur  to  the  subject.  We  will  confine  our- 
selves to  saying  that,  as  regards  the  tact  or  the  act, 
save  in  certain  cases  where  its  conception  and  execu- 
tion bear  the  plain  imprint  of  mental  alienation,  we 
may  accord  to  this  element  of  the  examination  taken 
singly^  only  a  secondary  and,  as  it  were,  an  accessory 
importance ;  it  certainly  deserves  consideration  by  the 
medical  legist,  but  it  ought,  in  order  to  acquire  all 
its  prominence  and  medico-legal  value,  be  considered 
only  m  an  abstract  waj^  and  never  be  separated  from 
its  agent. 

As  regards  the  individual,  the  author  of  the  act,  it  is 
evident  that  he  should  be  the  principal  object  of  the 
physician's  investigation.  And  this  investigation  to 
be  complete  should  be  carried  into  not  only  the  psy- 


654  MEDICO-LEGAL  PRACTICE. 

chological  phenomena,  but  also  into  the  external 
appearance  and  the  whole  of  the  organism ;  should 
include  not  only  the  actual  conditions  and  existing 
appearances,  but  also  the  past  conduct  of  the  sub- 
ject, his  antecedents  and  his  previous  acts. 

Wats  and  Means  of  the  Expertise. — The 
medico-legal  expertise  to  be  well  conducted  should 
be  based  on  the  three  following  methods  of  diagnosis : 
the  inquest,  the  interrogation,  the  direct  and  con- 
tinued observation. 

The  Inquest. — The  inquest  consists  in  collecting  all 
the  data  that  can  enlighten  the  expert  m  regard  to 
the  condition  of  the  insane  person,  and  on  the  nature 
of  his  delusions;  in  making  inquiry  as  to  his  hered- 
itary predisposition,  and  his  morbid  antecedents,  his 
tastes  and  inclinations,  his  habits  and  mode  of  life, 
before  and  after  the  outbreak  of  his  insanity;  the 
known  or  presumed  causes  of  the  disorder,  the  date 
of  its  beginning,  its  manner  of  invasion  and  develop- 
ment, its  most  striking  phenomena  and  most  char- 
acteristic symptoms,  and  finally  the  circumstances 
and  particular  details  of  the  act  of  which  he  is 
accused. 

These  data  may  be  obtained  from  various  sources ; 
from  tlie  relatives,  friends  and  neighbors  of  the 
individual;  by  visiting  the  places  where  he  has  lived, 
and  by  examining  his  writings ;  from  the  remarks, 
attestations  and  certificates  of  physicians;  in  the 
papers  of  the^court, 


WATS  AND  MEANS  OF  THE  EXPERTISE.    655 

The  legal  documents  and  medical  testimonies  have 
a  special  character  of  authenticity  which  gives  them 
in  the  eyes  of  an  expert  an  exceptional  value.  This 
is  not  always  true  on  the  contrary  with  the  data  ob- 
tained from  kinsmen  and  friends,  and  the  expert 
cannot  be  too  much  on  his  guard  against  the  hyper- 
bolic statements  and  erroneous  interpretations  of  some, 
and  the  studied  reticence  and  systematic  assertions 
of  others. 

We  will  not  dwell  here  upon  the  inspection  of  the 
dwelling  of  the  subject  and  the  analysis  of  his 
writings,  in  regard  to  which  we  have  already  spoken 
in  the  chapter  on  the  practical  diagnosis  of  mental 
alienation. 

Interrogation. — In  the  same  way,  as  regards  the 
interrogation  of  the  individual,  we  can  refer  to  the 
same  chapter  on  practical  diagnosis,  where  this 
question  has  been  treated  in  full  detail.  We  will 
limit  ourselves  to  mentioning  here  some  particular 
points  relative  to  medico-legal  interrogations. 

There  is  nearly  always  a  real  advantage  in  not 
having  recourse  to  the  personal  interrogation  until 
after  the  inquest,  that  is,  when  numerous  accurate 
data  have  already  made  known  the  habitual  and  dom- 
inant ideas  of  the  lunatic,  and  have  made  it  possible 
to  suspect  the  form  of  his  disease  and  shown  the  best 
method  to  be  followed  in  questioning  him.  We 
avoid  thus  having  to  grope  our  way  and  useless  loss 
of  time,  and  are  possessed  of  the  necessary  facts  to 


656  MEDICO-LEGAI.  PRACTICE. 

impress  a  more  methodic  and  efficacious  direction 
upon  the  interrogation. 

It  is  essential,  when  in  the  presence  of  an  insane 
person,  to  banish  all  apparatus,  all  solemnity  and  all 
appearance  of  harshness.  The  attitude  of  the  expert 
should  be  that  of  a  physician,  and  not  that  of  an 
examining  magistrate.  All  his  efforts  should  be  to 
dispel  the  distrust  or  fears  of  the  patient,  to  gain  his 
entire  confidence,  to  quiet  his  distracted  or  pre- 
occupied mind.  Preciseness  and  clearness  in  the 
questions,  simplicity  in  language,  kindness  and 
gentleness  in  words  and  manner,  plenty  of  skill,  tact, 
and  finesse,  firmness  when  required,  in  rare  and 
exceptional  cases  ability  to  use  intimidation  and 
menace;  such  are  the  qualities  and  disposition  that 
it  behooves  the  expert  to  bring  into  the  medico-legal 
interrogation  of  the  insane. 

In  the  periodic,  intermittent  or  transitory  forms 
of  insanity,  the  subject  may  have  recovered  his 
reason  at  the  time  of  the  examination.  Such  a  test 
would  then  be  of  no  value,  and  will  even  entail  the 
risk  of  drawing  false  conclusions.  The  fact  must 
not  be  lost  sight  of  that  in  certain  cases  the  delir- 
ium decreases  rapidly  and  disappears  suddenly  when 
the  transports  of  morbid  furor  are,  so  to  speak, 
satiated.  In  such  case,  however,  it  is  not  uncom- 
mon for  a  new  attack  to  appear  during  or  after  the 
judgment,  and  thus  prove  the  genuineness  of  the 
former  one.  Hence  the  rule  for  the  expert  to  pro- 
ceed to  the  interrogation  as  soon  as  possible,  during 


WAYS  AND  MEANS  OF  THE  EXPERTISE.    657 

the  active  period  of  the  insanity;  hence  also  the 
necessity  for  him  to  have  frequent  recourse  to  the 
third  method  of  investigation,  direct  and  continued 
observation. 

Direct  and  Continued  Observation. — Whenever 
the  inquest  and  personal  interrogation  have  failed  to 
dissipate  the  doubts  of  an  expert  and  settle  his 
opinion,  he  is,  after  a  fashion,  compelled  to  supple- 
ment it  by  personal  observation.  Many  of  the 
insane  have  sufficient  self-control  to  impose  upon  the 
public,  and  to  contain  themselves  before  the  magis- 
trates and  the  physicians.  But  left  to  themselves, 
they  throw  off  the  mask  and  loosen  the  rein  to  all 
their  extravagant  ideas.  By  the  aid  of  an  assiduous 
persevering  surveillance  skilfully  managed  and  prac- 
tised without  their  knowledge,  one  is  enabled  to  ascer- 
tain the  truth  and  take  them,  as  it  were,  in  the  act 
of  mental  derangement. 

It  is  especially,  however,  in  the  complicated  cases, 
and  those  presenting  difficulties  in  their  diagnosis, 
that  the  direct  and  continuous  observation  of  the 
patient  becomes  most  useful  in  enabling  the  expert  to 
completely  enlighten  himself.  The  chief  difficulties 
met  with  in  this  regard  are :  disshniilation^  simu- 
lation and  allegation  of  insanity.  We  will  say  a 
word  on  each  of  these. 

Dissimulated  Insanity. — There  are  certain  forms 
of  insanity,  the  systematized  or  partial  insanities  in 


658  MEDICO-LEGAL  PRACTICE. 

particular,  in  which  the  patients  are  naturally  in- 
duced, by  a  sort  of  pathological  tendency,  to  main- 
tain reticence,  and  to  conceal  their  delusions  with 
sufficient  skill,  occasionally,  to  impose  upon  those 
not  forewarned.  The  expert  must  not  confine  him- 
self to  questioning  these  lunatics.  Such  a  method 
of  investigation  could,  in  these  cases,  only  produce 
unsatisfactory  or  misleading  results.  It  is  needful 
to  submit  them  to  the  test  of  a  personal  and  pro- 
tracted observation,  to  scrutinize  their  sentiments 
and  instincts,  to  apply  to  their  actions  an  attentive 
control  and  scrupulous  surveillance;  to  make,  if 
possible,  the  inventory  of  their  lives ;  to  question  the 
wife,  the  children,  the  relatives,  that  is  to  say,  all 
the  habitual  witnesses  and  neglected  victims  of  their 
extravagances  and  madness. 

Simulated  Insanity. — An  accused  person,  a  con- 
script, or  a  soldier  presents  himself  with  the  apparent 
symptoms  of  insanity :  all  three  have  a  like  interest 
in  passing  themselves  off  as  insane,  the  one  in  the 
hope  of  gaining  freedom  form  punishment,  the  others 
in  the  hope  of  escaping  military  service.  Is  the 
insanity  feigned  or  genuine?  Such,  under  these  cir- 
cumstances and  others  similar  to  them,  is  the  question 
to  be  answered  by  the  medical  expert.  Following 
Tardieu,  we  will  examine  successively;  a. — the 
forms  of  insanity  simulated;  h. — the  methods  of 
simulation;   and  c. — the  means  of  detecting  fraud. 

a. — Forms  of  Insanity  Simulated. — Not  all  the 


SIMULATED  INSANITY.  659 

forms  of  insanity  favor  simulation  equally,  and  there 
are  some  which,  on  account  of  the  special  facility 
they  seem  to  offer,  are  most  frequently  tried  by  im- 
postors. Of  this  number  are :  acute  mania^  of  which 
the  state  of  excitement,  the  loquacity,  and  the  dis- 
ordered gesticulation  seem,  indeed,  very  easy  to 
counterfeit;  dementia^  of  which  the  essential  element, 
the  loss  of  intelligence  and  memory,  it  appears  to  be 
merely  play  to  realize ;  melancholia^  and  especially 
melancholia  with  stupor,  which  apparently  only  de- 
mands of  the  simulator,  a  mask  of  immobility  and 
inertia;  ambitious  insanity^  and  in  general,  all  the 
partial  insanities,  which,  for  the  fact  that  they 
turn  on  a  more  or  less  fixed  and  limited  num- 
ber of  ideas,  offer  a  less  complex  theme  and 
a  less  difficult  role  to  sustain.  We  may  mention 
also  the  toxic  insanities  in  this  connection, 
and  alcoholic  insanity  in  particular,  often  sim- 
ulated of  late  years  by  certain  criminals  who  hoped 
thus  to  escape  the  rigors  of  the  law  by  trying  to 
throw  the  blame  on  an  act  committed  under  the  tem- 
porary effects  of  intoxication.  Finally  should  be 
added  epilepsy  and  epileptic  insanity  which  always 
hold  one  of  the  first  places  when  we  are  treating 
of  simulation. 

b. — The  Methods  of  Simidation. — "I  do  not 
believe,"  says  Georget,  "that  an  individual  who  has 
not  studied  the  insane  could  so  imitate  insanity  as  to 
deceive  a  physician  well  acquainted  with  the  disease." 


660  MEDICO-LEGAL  PRACTICE. 

In  fact  nothing  is  more  difficult  to  counterfeit  than 
is  mental  alienation.  Imbued  with  the  common 
notion  that  all  the  acts  of  lunatics  are  extravagant, 
that  all  their  discourse  is  lacking  sense,  those  who 
borrow  the  mask  of  insanity,  make  excessive  gestic- 
ulations, perform  ridiculous  actions  and  utter  inco- 
herent speeches.  They  invariably  give  silly  and 
absurd  answers  to  questions  addressed  to  them,  with- 
out consecutiveness  or  connection,  in  which  they 
misconstrue  all  that  is  asked  of  them,  so  that  instead 
of  giving  a  faithful  likeness  of  insanity,  they  make 
an  outrageous  burlesque  and  parody  of  it.  In  the 
instance  of  Derozier,  reported  by  Morel,  when  asked 
his  age,  the  impostor,  after  hesitating,  replied  245 
francs  35  centimes,  or  rather  5  metres,  75  centimetres ; 
to  a  question  in  regard  to  his  family,  his  brothers, 
his  children,  he  answered,  "I  am  well  supplied  with 
coupons."  In  a  second  questioning,  Derozier  was 
asked  if  it  was  day,  he  answered  that  it  was  night ; 
his  age,  he  replied  that  he  was  king  of  BeauA^ais ; 
when  asked  to  give  his  right  haiid,  he  invariably 
gave  his  left ;  the  left,  and  he  gave  his  right  hand. 
There  is  in  all  the  answers  and  in  all  the  acts  the 
evident  and  calculated  intention  to  deceive,  and  to 
seek  the  absurd,  which  fits  poorly  with  the  characters 
of  true  insanity,  so  natural,  so  logical  and  so  true 
in  all  its  manifestations,  even  those  that  are  most 
extravagant. 

Thus,  and  it  is  an  important  fact  to  keep  in  mind, 
the  genuine   lunatic  is  a  patient  in  whom   all  the 


SIMULATED  INSANITY.  661 

various  symptoms  of  insanity  reveal  themselves  with- 
out effort  and  without  parade;  the  simulator  is  a 
comedian  who  plays  a  part  and  who  can  never  re- 
frain from  exaggerating  and  grimacing  under  the 
mask  he  has  assumed. 

Another  important  peculiarity  of  simulation  is  the 
lack  of  exactness  of  the  clinical  picture  presented  by 
the  subject,  who,  if  he  attempts  to  offer  certain 
symptoms  of  the  type  of  insanity  adopted,  omits 
certain  others  just  as  essential,  or  replaces  them  by 
others  not  reconcilable  with  this  form.  Further,  the 
impostor,  incapable  of  realizing  in  its  successive 
steps  the  regular  process  of  the  affection  he  coun- 
terfeits, persists  indefinitely  in  the  same  attitude  and 
the  same  role,  or  on  the  other  hand  he  modifies  his 
behavior  and  speech  according  as  he  feels  himself 
watched,  or  as  he  believes  he  can  do  better  by  the 
change.  The  case  reported  by  Montegya  is  well 
known  in  which  the  physicians  charged  with  the  ex- 
amination of  an  individual  suspected  of  simulation, 
said  in  his  presence,  so  as  to  be  heard,  that  they  had 
doubts  of  the  genuineness  of  the  insanity  of  the  ac- 
cused for  several  reasons :  first,  because  he  scattered 
the  food  given  him ;  second,  because  he  did  not  sigh ; 
and  third,  because  he  did  not  look  fixedly  on  any 
object.  The  ruse  succeeded,  the  simulator  modified 
his  comedy  in  such  a  manner  as  to  instantly  relieve 
the  doubts  of  the  physicians. 

c. — Methods  of  Discovering  Sinndation. — Al- 
though, properly  speaking,    there    is  no  particular 


662  MEDICO-LEGAL  PRACTICE. 

method  of  discovering  simulation,  there  are,  never- 
theless, certain  rules,  the  knowledge  of  which  may 
be  under  such  circumstances,  very  useful  to  the 
physician. 

"A  first  principle,"  says  Tardieu,  "that  should 
never  be  ignored  in  these  cases,  is,  to  give  no  opin- 
ion until  after  prolonged,  repeated,  persevering, 
and,  so  to  speak,  incessant  observation,  carried  on, 
if  not  directly,  at  least  indirectly,  by  persons  suffi- 
ciently experienced  and  familiar  with  the  insane." 
It  is  for  this  reason,  that  it  is  always  preferable  to 
transport  the  subject,  as  is  usually  done,  to  an  in- 
sane asylum  where  he  can  be  more  efficiently^  ob- 
served, or  where  he  may  in  contact  with  genuine 
lunatics,  change  his  behavior  in  a  way  to  betray 
himself,  or  where  he  sometimes,  tiring  of  his  sojourn 
in  such  surroundings,  at  last  gives  up  his  simulation. 

It  has,  from  all  time,  been  recommended,  as  a 
proper  procedure  to  unmask  simulation,  to  use  meth- 
ods of  harshness  and  repression  toward  the  sus- 
pected individual,  such  as  the  employment  of  chloro- 
form or  ether,  blisters,  moxas,  scarifications,  the 
actual  cautery,  energetic  douches,  etc.,  etc.  With 
Tardieu,  who  raised  his  voice  against  these  painful 
and  sometimes  even  dangerous  tests,  we  proscribe 
all  these  trulj^  inhuman  methods,  and  only  accept, 
in  this  line,  such  really  inoffensive  procedures,  like 
the  sojourn  or  the  accused  in  a  ward  of  disturbed  or 
untidy  patients,  to  weary  his  patience,  and  like  a 
eham  medication  composed  of  water  with  some  dis- 


SIMULATED  INSANITY.  663 

agreeable  or  nauseous  substance  added,  to  disgust 
him. 

In  reality,  it  is  chiefly  on  his  own  experience  and 
sagacity  that  the  physician  must  rely  in  discovering 
simulation.  B}^  multiplied  and  well  conducted  in- 
terrogations, strict  observation,  a  surveillance  with- 
out relaxation,  carried  on  night  and  day  without 
the  knowledge  of  the  party  observed,  by  methods 
skilfully  adopted  to  put  his  distrust  to  sleep,  nets 
carefully  spread  to  provoke  inconsiderate  words, 
imprudent  writings,  or  compromising  actions :  such 
arc  the  more  correct  methods  for  reaching  this 
result. 

One  of  the  principal  rules  in  an  expertise  of  this 
nature  consists  in  submitting  to  a  careful  examina- 
tion the  different  bodily  functions  of  the  individual. 
In  fact  it  is  especially  in  this  regard  that  simulation 
is  difficult,  and  of  certain  symptoms  impossible. 
There  is  insomnia  which  pseudo-lunatics  hardly  at- 
tempt; analgesia  so  frequent  in  genuine  lunatics; 
irregularity  of  the  appetite,  constipation,  and  above 
all  the  disorders  of  the  circulation  and  respiration,  so 
characteristic  in  the  generalized  insanities,  and  which 
it  is  clearly  impossible  to  counterfeit.  Thus  the  sham 
melancholiac,  however  easily  he  assumes  the  mask 
of  torpor,  never  succeeds  in  presenting  the  lowering 
of  the  bodily  temperature,  the  slowness  of  pulse  and 
respiration,  and  especially  the  violaceous  chilling  of 
the  extremities,  that  are  so  manifest  in  true  melan- 
cholia.    If  necessary  the  thermometer  and  sphygmo- 


664  MEDICO-LEGAL  PRACTICE. 

graph  can  be  employed,  as  has  been  done  by  M. 
Voisin  in  simulated  epilepsy. 

Another  sign  is  the  facial  expression,  on  which 
M.  A.  Laurent  has  judiciously  laid  stress  in  his  excel- 
lent monograph  on  simulation  of  insanity.  "The 
aspect  of  the  simulator,"  says  that  author,  "  is 
furtive,  changeable,  and  sly.  The  countenance 
indicates  forced  expression,  an  unpleasant  and  sig- 
nificant lack  of  harmony.  The  criminal  simulator 
cannot  give  to  his  face  the  wild  and  excited  appear- 
ance that  belongs  to  the  maniac.  We  recognize 
there  only  effrontery,  and  not  mental  aberration. 
Neither  can  he  assume  the  genuine,  indifferent  and 
enfeebled  expression  of  the  dement  and  paretic,  fixed 
gaze  of  the  stuporous  patient,  the  proud  and  haughty 
look  of  the  monomaniac,  etc.  He  cannot  conceal 
the  attention  he  gives  to  every  word  and  motion  of 
him  who  is  charged  with  studying  his  words  and 
gestures;  and  very  often  he  casts  down  his  eyes, 
distrusting  the  expression  his  looks  might  betray." 

A  difference  still  to  be  noted  between  the  genuine 
and  the  false  lunatic  is  that  the  former  is  generally 
rather  inclined  to  conceal  his  insanity  and  in  any  case 
to  deny  it  and  defend  himself  from  the  imputation, 
while  the  simulator,  on  the  contrary,  seeks  constantly 
to  give  evidence  of  his  insanity,  he  plumes  himself 
on  it,  so  to  speak,  and  is  never  so  extravagant  as  when 
he  finds  himself  in  the  presence  of  those  called  to 
examine  and  judge  him. 

Finally,  it  must  not  be  forgotten,  in  expertises  of 


ALLEGED  INSANITY.  665 

this  kind,  that  the  insanity  may  have  broken  out 
after  the  commission  of  the  act  of  which  the  person 
is  accused;  that  the  subject,  ah-eady  more  or  les8 
truly  insane,  may  simulate  or  rather  exaggerate  his 
delirium,  a  phenomenon  noticed  many  times  by 
numerous  observers,  and  it  has  even  been  said  by 
some  that  it  is  necessary  to  be  more  or  less  insane  to 
simulate  insanity;  finally,  that  the  prolonged  simu- 
lation of  insanity  may,  in  the  long  run,  have  an 
injurious  effect  on  the  faculties  of  the  subject,  and 
even  disorder  more  or  less  profoundly  the  intellect. 
Many  exposed  simulators  have  admitted  that  they  felt 
they  were  becoming  insane,  and  that  they  would  not 
again  begin  to  play  such  a  part,  even  to  save  their 
lives.  "You  cannot  believe  what  I  have  suffered," 
said  the  unmasked  Derozier  to  Morel,  "I  believed  I 
was  really  becoming  insane,  and  I  have  more  fear  of 
becoming  a  lunatic  than  of  going  to  prison." 

Alleged  Insanity. — A  misdemeanor  or  crime  has 
been  committed ;  the  accused  person  is  in  the  grasp 
of  the  law ;  he  does  not  pretend  to  be  now  insane, 
but  he  protests,  either  personally  or  through  his 
counsel,  that  his  mind  Avas  astray  at  the  time  of  the 
act,  that  he  was  under  the  influence  of  this  transient 
delirium,  dream  or  hallucination,  when  he  committed 
the  act.  Undoubtedly,  in  cases  of  this  kind,  a 
minute  analysis  of  the  circumstances  that  preceded, 
accompanied  or  followed  the  act,  may  furnish  useful 
indications ;  nevertheless,  the  expert  should  remember 

AlffiiT.  M£D.-42. 


666  MEDICO-LEGAL  PRACTICE. 

expressly  that  cases  of  sudden  and  transitory  insanity 
are  rarely  observed,  not  to  say  never,  in  persons  ab- 
solutely sound  in  mind  and  body,  but  that  such  con- 
ditions are  generallj^  the  sign  or  the  result  of  an 
ignored  hereditary  predisposition,  unrecognized  ver- 
tigo, a  threatening  meningo- encephalitis,  or  of  a 
larvated  mental  derangement,  or  one  in  the  period  of 
incubation.  It  is,  therefore,  indispensable  that  all 
the  investigations  should  be  guided  by  these  consider- 
ations. 

Medico-legal  Reports. — His  examination  fin- 
ished, it  remains  for  the  physician  to  formulate  the 
result  and  to  make  known  his  conclusions  under  the 
form  of  a  written  document,  which  bears,  as  we 
have  stated,  the  name  of  a  medico-legal  report.  It 
seems  unnecessary  to  reproduce  here  models  of  these 
reports,  as  I  did  in  the  previous  edition  of  this  work. 
I  refer  those  who  wish  it  to  the  remarkable  report 
of  my  friend.  Dr.  Parant,  on  the  murderer  of  Dr. 
Marchant,  to  the  reports  of  Blanche,  Lasegue,  and 
Legrand  du  Saulle,  and  particularly  to  the  acute  and 
excellent  reports  of  my  master  and  friend,  M.  Motet, 
some  of  which  are  veritable  clinical  and  literary 
masterpieces,  and  which  unhappily  remain  always 
unpublished  or  scattered  in  the  pages  of  special 
reviews. 

Asylums  for  Insane  Criminals. — When,  after 
a  medico-legal  expertise,  the  accused,  declared  irre- 


ASYLUMS  FOR  INSANE  CRIMINALS.  667 

Bponsible,  has  been  the  object  of  an  ordinance  of 
non-suit,  it  yet  remains  to  be  asked,  what  shall  be 
done  in  regard  to  this  unfortunate. 

Is  it  necessary,  assimilating  him  with  the  ordinary 
insane,  to  simply  confine  him  in  an  insane  asylum, 
without  having  his  retention  there  and  his  release 
conditioned  by  some  special  regulations  ?  Or,  on  the 
contrary,  is  it  necessary  to  separate  him  from  the 
other  insane,  and  to  confine  him  in  a  special  asylum, 
like  that  of  Broadmoor  in  England  (criminal  lunatic 
asylum),  or  in  an  annex  to  a  prison  like  that  existing 
in  the  Maison  centrale  of  Gaillon,  France,  and  to 
subject  his  detention  and  his  restoration  to  liberty 
to  specially  devised  x'ules  ? 

Such  is  the  important  question  at  present*  under 
discussion  in  France,  in  a  scientific  point  of  view  by 
the  savants^  and  in  a  legislative  point  of  view  by  the 
commission  charged  with  the  elaboration  of  the  new 
law. 

Without  taking  sides  in  this  important  question 
we  will  confine  ourselves  to  saying  that  the  majority 
incline  to  the  creation  of  special  State  asylums  for  the 
insane,  not  criminals,  since  the  two  terms  are  incom- 
patible, but  for  lunatics  whose  tendencies  are  espe- 
cially^ vicious  and  dangerous.  Among  the  numerous 
reasons  of  divers  orders  which  have  provoked  this 
solution,  there  should  be  specially  mentioned  the  need 
felt,  on  account  of  the  present  tendency  to  increase 
more  and  more  the  liberty  of  the  patients  in  the  asy- 

*1891. 


GG8  MEDICO-LEGAL  rHACTICE. 

Inms,  of  separating  inoffensive  insane  from  those 
really  dangerous,  whose  presence  with  the  former 
■would  suit  poorly  with  the  increase  of  freedom  that 
is  proposed.  I  may  add  that  in  the  ordinary  asylums 
the  criminal  insane  mingled  with  the  others  recover 
their  liberty  with  a  deplorable  facility,  and  that  it  is 
not  uncommon  to  meet  before  the  courts  irresponsi- 
ble, incorrigible  recidivistes,  who,  leaving  an  asylum 
for  the  fifth,  sixth,  or  the  tenth  time,  are  arrested  at 
once  for  a  new  misdeed,  often  the  same  as  before, 
and  it  is  only  too  fortunate  if  their  morbid  tendencies 
are  not  found  aggravated  at  each  arrest. 


THE  END 


TABLE  OF  CONTENTS. 


PART    FIRST. 

MENTAL   PATHOLOGY. 


HISTORICAL. 

First  Epoch  (Primitive  Epoch).  Second  Epoch — 1.  Hippo- 
cratic  period;  2.  Alexandrian  period;  3.  Grseco-Roman 

♦  period;  Asclepiades;  Celsus;  Arctaeiis;  Soranus;  Ccel- 
ius  Aureliauus;  Galen.  Third  Ej)och — 1.  The  ]Middle 
Ages;  2.  The  Penaissance;  Paul  Zacchias;  Sydenham; 
Willis;  Bonet;  Vieusscns;  Boerhaave;  iSaiivages;  Lorry; 
Cullen.     Fourth  Epoch  (Modern  Epoch),  Pinel,  etc. .  1-28 

FIRST   SECTION, 

GENERAL  PATHOLOGY 

Chapter  I. 

§  I. — Definition 29 

Distinction  between  Lisanity  and  Mental  Alienation. 
Synonymy,  Terminology 29-32 

§  IL— Etiology 32 

Predisposing-  Causes.  Civilization,  Pace.  Religious 
Ideas.  Political  Events.  Wars.  Heredity.  Age. 
Sex.  Climate.  Seasons.  Lunar  Phases.  Civil  Condi- 
tion.    Profession.     Education 32-44 

OccAsiON.\L  Causes.  1.  Moral  Causes.  Passions.  Emo- 
tions, Imitation.  Solitary  Confinement.  2.  Physical 
Causes,  a.  Local  Caiises.  Direct.  Sympathetic. 
b.  General  Causes.  AnoBmia.  Cachexia.  Diatheses. 
Fevers,     c.  Physiological  Causes,    a.  Spccijic  Causes,  4.i-i.S 


670  TABLE  OP  CONTENTS. 

§  III. — Progress 48 

Distinction  of  Insanity  into  Acute  and  Chronic.  Begin- 
ning of  Insanity.  Passage  to  tbe  Chronic  Condition. 
Different  Types  of  the  Evolution  of  Insanity.  Remis- 
sion.    Intermissions.     Lucid  Intervals 48-51 

§  IV. — Duration 51 

Duration  of  Subacute  Insanity.  Transitory  Insanity. 
Duration  of  Acute  Insanit3^  Duration  of  Chronic  In- 
sanity    51-52 

§  V. — Terminations. — Complications 52 

Recovery.  Incurability.  Death.  Complications.  Inci- 
dental Disorders.     Crises 52-54 

§  VI. — Prognosis 54 

Prognosis  from  the  Character  of  the  Disease.  Prognosis 
Deduced  from  the  Patient  Himself.     Relapses 54-57 

§  VII. — Pathological  Anatomy 57 

Pathological  Anatomy  of  Mental  Alienation  in  General. 
Pathological  Anatomy  of  Insanity,  a.  Acute  Insanities. 
h.  Chronic  Insanities 57-60 

Chapter  II. 

Stmptomatic  Elements  of  Mental  Alienation. 

§  I.  Functional  Elements 61 

1.  Disorders  of  Oeneral  Activity.    (Excitement,  depression)  62 

2.  Disorders  of  the  Psychic  Sphere:  delusive  conceptions; 
hallucinations  (definition,  division,  nature,  hallacin- 
ations  without  insanity,  hypnagogic  hallucinations, 
hallucinations  of  hearing,  of  sight,  of  smell  and  taste, 
of  general  sensibility,  genital  hallucinations),  illusions 
(definition,  division,  characters,  internal  illusions, 
mental  illusions),  insanity  of  the  sentiments,  of  the 
instinct,  of  acts,  impulsions, 63-78 

8.  Disorders  of  the  Physical  Uphere,  disorders  of  nervous 
functions  (sleep,  sensibility,  motility),  disorders  of  the 
vegitative  functions  (circulation,  respiration,  nutrition 
and  assimilation,  secretions,  temperature,  trophic  and 
vaso-motor  functions,  appendix 78-111 


TABLE  OF  CONTENTS.  671 

§  II. — Constitutional  Elements Ill 

1.  Lesions  of  Organization:  psychic  stigmata,  physical 
stigmata  (stature,  limbs,  cranium,  face,  encephalon, 
eyes,  vision,  ears  and  hearing,  mouth  and  teeth,  genital 
organs,  skin,  larynx,  voice) 111-119 

2.  Lesions  of  Disorganization 119 

Chapter  III. 

ClASSEFICATION  OP  MeNTAI  DISEASES. 

Division  of  classifications :  classification  of  M.  Baillarger, 
classification  of  M.  Ball,  classification  of  M.  Magnan, 
classification  of  Hack-Tuke,  classification  of  Krafft- 
Ebing;  international  nomenclature  of  the  Congress 
of  1889 ;  the  author's  classification 121-144 


SECOND  SECTION. 

SPECIAL  PATHOLOGY. 

Chapter  IY. 

Maota. 

§  I. — Acute  Majoa  (typical  mania) 146 

Definition,  etiology,  symptomatology,  termination,  course 
and  duration,  pathological  anatomy,  prognosis,  diag- 
nosis, treatment 146-157 

§  II. — Subacute  j\L\nia  (maniacal  excitation) 157 

Definition,   etiology,  course,  duration  and  termination, 

prognosis,  pathological  anatomy,  diagnosis,  treatment, 

157-163 

§  III. — Hyperacute  Mania  (acute  delirium) 163 

Definition,  etiology,  description,  pathological  anatomy, 

diagnosis,  treatment , 162-165 

§  IV. — Chronic  jVIania 165 

§  V. — Kemittent  and  Intermittent  Mania 166 


672  TABLE  OF  CONTENTS. 

Chaptek  v. 
Mela2?cholia  or  Ltpemania. 

§  I. — Acute  Melancholia  (typical  melancliolia) 170 

Definition,  etiology,  symptoms,  termination,  forms, 
course  and  duration,  pathological  anatomy,  prognosis, 

diagnosis,  treatment 170-182 

g  II. — Subacute  Melancholia,  (melancholic  depression)  182 
Etiology,    description,    course,    duration,    termination, 
pathological  anatomy,  diagnosis,  treatment 182-185 

§  III. — Hyperacute  Melancholia  (melancholia  with 
stupor) 185 

Definition,  etiology,  description,  course,  duration,  ter- 
mination, pathological  anatomy,  treatment 185-187 

§  IV. — ChPvONic  Melancholia 188 

§  V. — Remittent  and  Intermittent  Melancholia.  .  189 

Chapter  YI. 

Double  Form  Insanitt. 
(Circular  Insanity,  Insanity  of  Alternating  Forms). 

Definition,  etiology,  description,  course,  duration,  ter- 
mination, pathological  anatomy,  prognosis,  diagnosis, 
treatment 191-200 

Appendix. 
Graphic  representation  of  the  generalized  insanities. . . .  201 

Chapter  VII. 
(Partial  or  Essential  Insanities). 

§  I. — Generalities 212 

§  II. — Progressive  Systematized  Insanity 218 

Definition,  etiology;  1,  period  of  subjective  analysis 
(hypochondriacal  insanity);  2,  period  of  delusional  ex- 
planation (delusions  of  persecution  or  Lasagne's  dis- 
ease), mystic  insanity  (religious  insanity),  erotic, 
political,  jealous  insanity ;  3.  period  of  transformation 
of  tlie  personality  (amljitious  insanity),  course,  dura- 
tion, termination,  prognosis,  pathological  anatomy, 
diagnosis,  treatment 218-240 


TABLE  OF  CONTEXTS.  673 

Chapter  VIII. 

Degeneracies  of  Evolution. 
(Vices  of  Organization). 

§  I. — Disharmonies 243 

111  balanced  individuals,  original,  eccentric  individuals, 

242-246 

§11, — Neurasthenias  (fixed  ideas,  impulsions,  aboulias)  246 

Generalities,  cerebral  neurasthenia  (obsessions),  impul- 
sive veurastheriias  or  obsessions  (general  characters), 
maladie  du  doute,  fear  of  objects,  agoraphobia,  crem- 
nophobia,  acrophobia,  potamophobia,  claustrophobia, 
astraphobia,  nosophobia,  anthropophobia,  mono- 
pliobia,  onomatomania,  arithmomania,  convulsive  tics, 
kleptomania,  pyromania,  dipsomania,  impulsion  to 
suicide  and  homicide,  erotomania)  aboulic  neurasthenias 
or  obsessions,  (general  characters,  ananabasia,  ananas- 
tasia,  anesthia,  auupographia,  aprosexia,)  diagnosis, 
prognosis,  treatment 246-287 

§111, — Phren asthenias  (hereditary  insanity,  or  insanity 
of  the  degenerates) 287 

General  characters,  delusional  phrenastJienins  or  insanity 
of  the  degenerates  (persecuted,  ambitious,  litigious, 
erotic  and  jealous;  mystics,  regicides,  folie  a  deux), 
reasoning  pftrenasthenias  or  moral  insanity,  instinctive 
phrenasthenia  or  criminal  psychosis,  287-307 

§  IV.— Monstrosities 307 

Inibecility,  idiocy  (division,  description,  etiology,  path- 
ological anatomy,  diagnosis,  prognosis,  treatment,; 
cretinism  (definition,  division,  cretinoids,  semi-cretins, 
complete  cretins,  etiology,  nature,  treatment,  sporadic 
cretinism  or  cretinoid  idiocy) 307-322 

Degenekacies  of  Involution. 
(Disorganization). 

Simple  Dementia , 323 

Definition,  etiology,  description,  duration,  pathological 

anatomy,  treatment 323-327 

Secondary  Conditions  of  jVIentajl  Alienation.  .  328-330 


674  TABLE  OF  CONTENTS. 

Chapter  IX. 

Insajoties  Associated  with  Phtsiologicax  Coitoitions. 
(Sympathetic  Insanities). 

§1. — Insanity  of  Childhood  and  Puberty  (hebe- 
pbrenia) 331 

§  II. — Insanity  op  Old  Age  (senile  insanity) 335 

§  III. — Insanity  of  Menstruation  (menstrual  insanity)  338 

§  IV. — Puerperal  Insanity 340 

1.  Insanity  of  pregnancy 343 

2.  Insanity  of  childbed 342 

3.  Insanity  of  the  puerperal  state 343 

4.  Insanity  of  lactation 344 

Prognosis,  treatment 344 

§  V — Insanity  of  the  Menopause  (climacteric  insanity)  345 

Chapter  X. 

Iksanttees  Associated  with  Local  Visceral  Disease. 
(Sympathetic  Insanities). 

§1. — Insanity  Connected  with  Disorders  of  the  Gen- 
ital AND  Genito-urinary  Organs 348 

1.  Utero-ovarian  insanity 348 

2.  Brightic  insanity 351 

§11. — Insanity  Connected  with  Disorders  of  the 
Digestive  Tracts,  Diseases  of  the  Liver  and 
Intestinal  Worms 355 

1.  Insanity  connected  with  diseases  of  the  digestive 
organs 355 

2.  Insanity  connected  with  diseases  of  the  liver  and  bil- 
iary passages 358 

3.  Insanity  connected  with  helminthiasis  (verminous 
insanity).'. 359 

§  III. — Insanity  Connected  with  Diseases  op  the 
Circulatory  Apparatus 362 


TABLE  OF  CONTENTS.  675 

1.  Insanity  connected  with  disease  of  the  heart  (cardiac 
insanity) 363 

2.  Insanity  connected  with  diseases  of  the  vessels 365 

§  IV. — Insanity  Connected   with  Disease   of    the 
Lungs 366 


Chapter  XI. 

Insantties  Connected  with  Generax  Diseases. 

§  I. — Insanity  of  the  Infectious  Diseases 367 

1.  Insanity  connected tcith  acute infectioiLS  diseases  (variola, 
erysipelas,  cholera,  typhoid  fever,  hydrophobia,  grippe 

or  influenza 367-378 

2.  Insanity  connected  with  chronic  infectious  diseases, 
intermittent  fever  (malarial  insanity),  tuberculosis, 
pellagra  (pellagrous  insanity  and  pellagrous  general 
paralysis),  syphilis  (syphilitic  insanity,  and  general 
paralysis) 378-397 

§  II. — Insanity  of  the  Diatheses  (diathetic  insanity) .  397 

1.  Arthritism  in  general 400 

2.  Rheumatism  (rheumatic  insanity) 406 

3.  Gout  (gouty  insanity) 409 

4.  Diabetes  (diabetic  insanity) 410 

5.  Cancer  (cancerous  insanity) 412 

Chapter  XII. 

Insanities  Associated  with  Disease  op  the  Nervous  Ststem. 

§  I. — Insanity  Connected  with  Brain  Disease  414 

1 .  General  paralysis 414 

Definition,  history,  paralytic  dementia,  prodroraic  or  pre- 
paralytic period,  primary  stage,  second  stage,  terminal 
stage,  insanity  associated  with  paralytic  dementia 
(paralytic  insanity),  course,  duration,  termination, 
pathological  anatomy,  diagnosis,  etiolog}'',  treatment, 

414-463 

2.  Apoplectic  dementia 463 


076  TABLE  OF  CONTENTS. 

§11. — Insanities  Associated  with  Diseases  of  the 
Spinal  Cord 465 

1.  Insanity  associated  with  locomotor  ataxia  (tabetic 
insanity) 465 

2.  Insanity  associated  with  multiple  sclerosis 466 

§111. — Insanities  Associated  with  the  Neuroses.    .467 

1.  Insanity  associated  with  epilepsy 467 

a.  Epileptic  mental  condition ;  b.  Epileptic  insanity  467 

2.  Insanlt}^  associated  with  hysteria 472 

a.  Hysterical  mental  coxidition;  J.  Hysterical  insanity  472 

3.  Insanity  associated  with  chorea 477 

a.  Choreic  mental  state ;  h.  Choreic  insanity 477 

4.  Insanity  connected  with  paralysis  agitans 482 

5.  Insanity  connected  with  exophthalmic  goitre 482 

Chapter  XIII. 

Insanities  Associated  with  the  Intoxications. 
(Toxic  Insanity). 

§  I. — Insanity  due  to  alcoholism 485 

Inebriety,  subacute  alcoholic  insanity,  acute  alcoholic  in- 
sanity, hyperacute  alcoholic  insanit3%  alcoholic  demen- 
tia, alcoholic  general  paralysis  and  pseudo-general 
paralysis 485-503 

§  II. — Insanity  due   to  Plu.mbism 503 

Subacute  saturnine  insanity,  acute  saturnine  insanity, 
hyperacute  saturnine  insanity,  saturnine  dementia, 
saturnine  pseudo-general  paralysis 503-511 

§  III. — Insanity  due  to  Morphinism 511 

a.  Effects  of  abuse;  b.  Effects  of  abstinence. . . .  511-518 

§IV. — Ins.\nity  due  to  Other  Intoxications 518 

1.  Intellectual  disorders  of  absinthism 518 

2.  "  "  "    etlierism 519 

3.  "  "  "     chloralism 519 

4.  "  "  "    cocainism 520 

5.  "  "  *'    oxy-carbonism 521 


TABLE  OF  CONTENTS.  C77 


SECOND   PART. 

PRACTICAL    APPLICATIONS    OF   MENTAL 
PATHOLOGY. 

First  Section — Medical  Practice 523 

Chapter  I.  ' 

The  Practical  Diagnosis  op  Mental  Alienation.  525 

1.  Commemorative 526 

Study  of  the  family,  antecedents  of  the  patient 526 

2.  Examination  of  the  patient 529 

Chapter  II. 

Medical  Opinion  as  to  Necessity  of  Sequestration. 

General  considerations,  consideration  relative  to  the 
patient,  considerations  drawn  from  the  disease,  danger- 
ous lunatics 544-558 

Chapter  III. 

Treatment  of  the  Insane. 

§  I. — Preventive  Treatment 559 

§  11^ — Curative  Treatment 560 

1.  General  agents:  a.  Isolation  (special  establishments, 
agricultural  colonics,  family  system,  county  residence, 
hydrotlicrapeutic  institute,  travels);  h.  non-restraint 
(open  door  asylums,  non-constraint).  2.  Special  agents : 
a.  Hygienic;  b.  psychic  (moral  direction,  sug- 
gestion); c.  Physical,  (hydrotherapy,  electrother- 
apy, massotherapy,  other  physical  agents,  bicycling); 
d.  Surgical  (trephining,  cerehrotomy,  craniectomy, 
revulsion,  thyroidectomy,  thyroid  grafts,  bloodletting, 
transfusion,  hypodermic  injections,  washing  of  the 
stomach,  forcible  feeding  or  gavage,  drugs  (purgatives, 
sedatives,  hypnotics,  tonics,  antiperiodics,  ditfusible 
stimulants,  emmenagogues, 560-600 

3.  T herapeutic  formulary 601-009 


678  TABLE  OF  CONTENTS. 

Chapter  IV. 

MEDICO-MENTAIi  DeONTOLOGT. 

Sexual  relations  between  a  deranged  person  and  consort, 
chances  of  beredity  of  the  different  members  of  the 
family  of  an  insane  person,  marriage  of  the  insane  and 
the  relatives  of  the  insane 610-626 

SECOND   SECTION. 

MEDICO-LEGAL  PRACTICE. 
Chapter  I. 

PENAi    ReSPONSEBIUTT  OF    THE  INSANE.      CRIMES    AJCD    MiSDEMEANOBS 

OF  THE  Insane. 

1.  Penal  responsibility  of  the  insane :  absolute  irrespons- 

ibility, partial  responsibility,  responsibility  in  the 
states  of  remission,  intermission,  lucid  intervals. .  629-637 

2,  Crimes  and  misdemeanors  of  the  insane :  general  char- 

acters, special  characters  in  the  principal  morbid 
forms,  in  the  degeneracies,  in  maniacal  states,  in 
melancholic  states,  in  systematized  insanity,  hebe- 
phrenia, puerperal  insanity,  toxic  insanities,  general 
paralysis,  epilepsy 637-649 

Chapter  II. 

MEDico-LEGAii  Expertise, 

Definition,  ways  and  means,  inquest,  interrogation,  direct 
and  continued  examination,  concealed  insanity,  simu- 
lated insanity,  alleged  insanity,  asylum  for  insane 
criminals ' 650-668 


INDEX. 


Aboiilias  (neurasthenias  or 

obsessions) 256,  280 

Absinthism  (mental    state 

in) 518 

Acrophobia 260,  270 

Activity,  general  (disorders 

of) 128,  145 

Adherences,  meningo-en- 
cephalic  in  general  pa- 
ralysis  444 

Age,  general  etiology ....  41 

Age,  critical 345 

Agoraphobia 260,  270 

Aichmophobia 260,  267 

Alciat 17 

Alcoholic  insanity,  487  ; 
subacute,     488  ;     acute, 

490 ;  hyperacute 493 

Alcoholic  dementia 496 

Alcoholic  general  paral- 
ysis  497 

Alcoholism 485 

Alexandrine  period.    ...  .1-9 
Alienation,      mental,      29 ; 
definition,    30 ;    different 

from  insanity 29 

Alimentation,     forced     or 

gavage 596 

Aliments,  refusal  of  in 
acute  melancholia,  178; 
in  gastro- intestinal  in- 
sanity   357 

Althaus 585,  591 


Amadei 575 

Ambitious  delusions,    234; 

in  general  paralysis. . .  .439 
Ambulatory  automatism .  278 

Amelung 26 

Amenorrhoea,  (insanity  in)339 

Ananabasia 281 

Ananastasia 281 

Anatomy,  pathological,  of 
mental  alienation,  57 ;  of 
insanity,  58;  (acute,   58; 

chronic) 59 

Anaemia  (general  etiology)  47 

Anesthia 283 

Anosmia 83 

Anglade 460 

Anthropophobia 272 

Anupographia 283 

Apoplectiform    attacks  in 

genera]  paralysis. .  436,  437 
Apoplectic  dementia. .. .  463 

Aprosexia 284 

Aretaeusof  CappadocialO,  11 
Argyll- Robertson  pupil. .   86 

Arithmomania 275 

Arnaud 458 

Aruozan 100 

Arnozan  and  Regis 321 

Arndt 585,  588 

Arthritism  (mental  state  in) 
400;  and  general  paral- 
ysis  404 

Arthritic  insanity 403 

Asclepiades 4-5 

Asclepiades  of  Bythinia. .  10 


G80 


HTDEX. 


Asylums,  open  door 568 

Asylums  for  criminal  in- 
sane   666 

Asphyxia     from    food    in 

general  paralysis 433 

Assimilation  and  nutrition  96 

Astrapiiobia 260,  271 

Asystoly  (delirium  of). .  .365 
Ataxia,  locomotor  (mental 

state  in) 465 

Aubanel 436 

Auditory  hallucinatians . .  67 
Autointoxication    in    in- 
sanity  108 

Anzouy , 412 

Avicenna 16 

Axenfeld  and  Huchard.  .402 
Azam 351 

B 

Baillarger,  27,  39,  66,  122, 
191,  199,  378,  380,    384, 

414,  499,  441 

Baillon 17 

Ball,  44,  64  122,  217,  262, 
271,    304,  323,  338,  341, 

381,  407,  482 

Ball  and  Faure 407 

Ball  and  Regis 404,  457 

Ball  and  Ritti 64 

Ballet 67,  483 

Bannister  and  Hektoen ...  36 

Bard 378 

Bartels 377 

Bayle 27,  415 

Bazin 412 

Beard 252,  272,  287 

Beard  and  Rockwell 608 

Belliomme 315 

Belie  res      and      Morel- La- 

vallee 395,  459 

Belle  and  Lemoine.  .182,  605 

Belonepliobia 267 

Bclous 376 


Bcnedikt 90 

Beni  Barde 581 

Bennett  (Alice) 352 

Bergerio 482 

Bergonie 583 

Berillon 575 

Bernheim 575,  634 

Besnier 409,  427 

Bettencourt  -  Rodrigues, 

108,  322,  429 

Biaute 381 

Billod 283,  387 

Blanche 666 

Bladder,  mental  disorder 

from  disease  of 354 

Blasphematory   (mania).  .275 
Bleeding,   in  treatment  of 

insanity 594 

Blocq 282 

Blood,  state  of  in  insanity.  100 

Boerhaave 19 

Bonet 17,  18 

Bonnet 376,  460 

Bonnet  (H.)  and  Poincarre447 

Bonnucci 626 

Bordaries 402 

Bouchard..  107,  108,  398,  409 

Bourne ville 315,  321 

Bourneville  and  SoUier  .  .118 

Bouvat 352 

Bouvet 376,  460 

Brain  in  the  insane,  59 ;  in- 
sanity   connected     with 

disea-se  of 414 

Briand , 521 

Brierre  de  Boismont 376 

Brightic  insanity 351 

Brosius 296 

Brouardel 369 

Brown-Sequard., 595 

Buccola 288 

Buccola  and  Morselli,  181, 

594,  605 

Buchanan 35 

Bucknill  and  Tuke 321 


rNT>EX. 


681 


Burkhardt 591 

Burrows 381 

Burrows  and  Ellis 381 


C 


Cachexia  (general  etiol- 
ogy)    47 

Calmeil 27,  417 

Camisole 569 

Cancer 412 

Cardiac  insanity. 362 

Casper 627 

Castration 593 

Catatonia 186 

Catrou 275 

Causes  of  insanity,  predis- 
posing, 33 ;  occasional, 
44;  physical,  46;  local, 
46:  general,  47;  physio- 
logical, 48;  specitic,  48  ; 

moral 44 

Celsus 9,  10,  11 

Cerebrotomy 591 

Cerise 317 

Chalmers  da  Costa 520 

Chambard 428 

Charcot... 275,  409,  480,  483 
Charcot  and  Magnan.  274,  282 

Chardon 108,367 

Charpentier 110 

Chaslin 80 

Chaslin  and  Seglas 186 

Chevalier-Lavaure 109 

Chiaruggi 24 

Childbed,  insanity  of 342 

Chloralism     (mental    state 

in) 519 

Chlorof  ormism     (mental 

state  in 519 

Cholera  (insanity  from) , .  370 
Chorea  (insanity  from) . . .  477 
Chorea,  Huntington's  (men- 
tal state  of) 480 

Ment.  Med.— 43. 


Choreic  insanity 477 

Chouppe 520 

Christian 463 

Christian  and  Ritti 458 

Circular  insanity 191 

Circulation  (disorders  of  in 

insanity) 93 

Civilization  (general  etiol- 
ogy)   33 

Civil    condition     ( general 

etiology) 42 

Classification,  121  ;  of 
Baillarger,  122;  of  Ball, 
123;  of  Magnan,  123;  of 
Hack  Tuke,  124;  of 
Krafet-Ebing,  124;  of  the 

author 126,  139 

Claustrophobia 271 

Climateric  (insanity  of) . . .  345 
Climate  (general  etiology)  41 

Clitoridectomy 593 

Clouston 381,  409 

Clouston  and  Skae 388 

Cocainism     (mental     state 

in) 520 

Coelius  Aurelianus..2,  10,  13 

Colin 476 

Colonies,  agricultural ....  562 
Complications  of  insanity  53 
Conceptions,  delusive.  63,  223 

Congestive  attacks 436 

Conolly 28 

Convulsibility,  reaction  of  90 

Coprolalia 275 

Cordes 270 

Corvisart 363 

Cotard 188,  410 

Cranium  in  the  insane. .  ..113 

Craniectomy 316 

Cremnophobia 270 

Cretinoids ...  316 

Cretinism,  317 ;  endemic, 
319;  sporadic,  320;  ex- 
perimental  323 

Cretinoid  idiocy 320 


682 


IKDEX. 


Crimes  of  the  insane,  637; 
general  character  of,  637; 
special  characters  of  in 
the  principal  morbid 
types,  639;  in  degenera- 
tions, 640;  in  mania,  642; 
in  melancholia,  643;  in 
systematized  insanity, 
644:  hebephrenia,  646; 
in  puerperal  insanity, 
646;  in  toxic  insanity, 
647;  in  general  paralysis, 
647;  in  epilepsy 649 

Criminal  psychosis. 305 

Criminals,  insane,  asylums 

for 666 

Criminal  born 805 

Crises  in  insanity 53 

Crystallophobia 267 

Cullen 20 

CuUerre 627 

Curling 821 

Cuylitz 114 


Dagonet 412 

Dangerous  lunatics 555 

Daquin 24 

d'Astros 863 

Da  vies,  Pritchard 462 

Death  iri  insanity 53 

Debove 483 

Decorse 412 

Duplicated  hallucinations  65 
Duplication  of  personality  69 
Defect  of  equilibrium. .  ..242 
Definitions  of  insanity ...  29 
Degenerates,  insanity  of. .  287 

Degeneracies  of  evolution, 
133,  241 ;  of  involution, 
140,  323;  crimes,  &c.  in,  640 

Degeneracy,  stigmata  of,  112 


Delasiauve 315,  507 

Delaye 27,  415 

Delirium,  acute 162 

Delirium  tremens 493 

Delmas  (of  Bordeaux). . .  .577 
Dementia,  simple,  323  ; 
maniacal,  439  ;  melan- 
choliac,  440;  ambitious, 
439;  alcoholic,  496;  sat- 
urnine  507 

Dental  stigmata 118 

Deontology,    medico-men- 
tal  610 

Depression 62 

Descourtis 72 

Deuxjolied 293 

Deventer 364 

Devouges 508 

Diabetes,  insanity  of 410 

Diagnosis  of  mental  aliena- 
tion  535 

Diatheses,      397 ;     general 
etiology,     47  ;    insanity 

of 397 

Dieulafoy 853 

Digestive  disorders  in  the 

insane 97 

Digestive  tracts,  insanity 

due  to  troubles  of 355 

Disharmonies 134,  243 

Digoy 480 

Diphtheria,    insanity  due 

to 369 

Dipsomania 277 

Double  form  insanity 191 

Doubting  insanity 261 

Doutrebente 51 

Dreams 79 

Dujardin-Beuametz 608 

Dumontpallier 575 

Duncan,  J.  M 888 

Duplaix 363 

Dupuytren's  disease  in  gen- 
eral paralysis 404 

Duration  of  insanity 50 


INDEX. 


G83 


Dynamy,  functional,  in 
general  paralysis 439 

Dysmenorrhcea,  insanity 
from 339 

E 

Ears  in  the  insaile 117 

Echo  of  thought 69,  223 

Echolalia 276 

Echomatism 276 

Eckokinesis 276 

Education    (general    etiol- 
ogy)   44 

Electrotherapeutics 583 

Elements,  fear  of 260 

Elements,  symptomatic  of 

mental  alienation 61 

Ellis  and  Burrows. 381 

Emotionalism  in  apoplectic 

dementia 464 

Emotional  insanity 74 

Emotions     (general    etiol- 
ogy)   74 

Ependymal  granulations  in 

general  paralysis 445 

Epidemics  of  religious  in- 
sanity  302 

Epilepsy    (legal    medicine 

of) 649 

Epileptiform  attacks 437 

Epileptic  insanity 467 

Epileptics,  mental  state  of  467 

Equilibrium,  sense  of 85 

Erasistratus 9 

Erb 583 

Erlenmeyer 520 

Erotic  insanity 232 

Erotomania 279 

Erysipelas,  insanity  from .  369 
Esquirol   2,    26,     27,     65, 

263,  356,  308,  415 
Establishments,  special . .  561 
Etherism,  mental  state  in, 519 
Etiology,  general 32 


Evolution,  lesions  of..  133,  241 

Ewart,  (C.  Theo) 591 

Eccentricity 242 

Excitation. 62 

Excitement,  maniacal 157 

Exhibitionists 279 

Expertise,  medico-legal,  650; 
definition  of,  650;  ways 
and  means  of,  654;  in- 
quest, 654;  interrogation, 
655;  direct  observation, 
657;  concealed  insanity, 
657;  simulation,  658; 
forms  simulated,  658; 
methods  of  simulation, 
659;  means  of  detection, 
661;  alleged  insanity.  .  .665 
Eyes,  condition  of,  in  the 
insane  84 

F 

Face  in  the  insane 113 

Fagge,  Hilton 321 

Falret,  Sr 27,  191,  198 

Falret,   Jules    28,    253,  262, 

288,  304,  415 

Falret.  Jules,  andLasegue304 

Faradization 5S7 

Fassy 410 

Faure -.  .  ...407 

Fears,  morbid 260 

Fere 66,  109,  117 

Ferri ,.627 

Ferrus 28 

Feyal 108 

Fevers,  (general  etiology).  .47 
Fever,  intermittent,  insan- 
ity from 378 

Fever,  typhoid 370 

Fleming 407 

Fodere 28 

Folie  d  deux 40,  45,  304 

Fontan  and  Segard 575 

Forel 575 


684 


LNDEX. 


Fournier 389 

Foville,  Sr, 27 

Fovillc,  Acbille 239 

Franklinization 588 

Fraser 407 

Friedreich 26,  381 

Friese  and  Regis 4H2 

Frigerio 117 

Fiirstner 335 

G 

Gairdner 409 

Galen 2,  15 

Galvanization,  583;  cerebral 
585 ;  of  the  sympathetic .  586 

Garnier 216 

Garofalo 307 

Garrod 409 

Gardiner  Kill 28 

Gavage 596 

Gemellarj^  insanity 304 

Genital  organs,  state  of,  in 

insanit}^ 118 

General  etiology 32 

Geoffroy 412 

Georget 27,  38,  415 

Gheel 563 

Gilies  de  la  Tourette 275 

Giacchi 117 

Gintrac 386 

Girma 463 

Glycosuria,  insanity  from. 410 
Goitre,  exophthalmic,  men- 
tal state  of 482 

Goldsmith 389 

Gout,  insanity  from 409 

Goutj"  insanity 409 

Graphic  representations  of 
generalized  insanities.  .201 

Grediug 356 

Greenlecs,  Duncan 93 

Griesinger, 26,  378,  412 

Grinding  of  teeth  in  general 
paralysis 432 


Grippe,  insanity  from. . .  .376 

Grisolle 504 

Griibelsucht 262 

Guimbail 512,  517 

Guislain 28,  412 

Gynephobia 273 

H 

Haschischism,  mental  state 

of 520 

Hallopeau 520 

Hallucinations,  65 ;  "without 
insanitv,  67;  of  hearing, 
67 ;  of  sight.  70 ;  of  smell 
and  taste,  71 ;  of  general 
sensibility,  71 ;  genital.  .  .71 

Hammond 358 

Haslam 415 

Heart  disease,  insanity  of.. 362 

Hebephrenia 331 

Heinroth 26 

Hektoen  and  Bannister. . .  36 

Hellebore 8 

Helminthiasis,    insanity 

from 359 

Hcematoma  auris 434 

Heinroth. . .' 26 

Hematophobia 267 

Hepatic  insanity 358 

Hereditary  insanity 287 

Heredity,  general  etiology, 
38 ;  in  general  paralysis, 

456 ;  chances  of 613 

Herophilus 9 

Hesselbach 356 

Heyden  (von) 585 

Hippocrates 1,  5 

Hitzig 585 

Ploffbauer 627 

Hoffmann 497 

Holthof 356 

Homicidal,  impulse 278 

Horsley 322 

Huchard 365,  377 


INDEX. 


685 


Huchard  and  Axenfeld. .  .402 

Hughes 585 

Hurd..: 200 

Hydrophobia 376 

Hydrotherapy , .  . . .  577 

Hydrotherapeutic     insti- 
tutes   565 

Hygienic  agents 560 

Hypnogogic  hallucinations  67 

Hypnotism 574 

Hypochondriacal  insanity.  219 
Hypochondria  in  general 
paralysis 440 

I 

Ideas,  fixed 246 

Ideler 26 

Idiocy 808 

111  balanced  individuals.  .243 

Illusions 72,  73 

Imbecility 307 

Imitation 44 

Imprisonment,  solitary. .  .  45 

Impulsions 77,  246 

Incurability 52 

Indecisions  (ob.sessions) .  ..261 

Induced  insanity 304 

Inebriety 485 

Infectious  diseases,  insanity 

of 367 

Infectious  diseases,  acute.  367 
"    chronic.  378 

Influenza,  insanit}^  of 376 

Infancy,  insanity  in 331 

Insanity,  intellectual.. 63,  212 
Insanity  of  feelings,  emo- 
tions   62 

Insanity,  of  instinctive. ..  75 

"  acts 76 

"  double  form..  191 

"  definition 31 

"  etiology 32 

"        "  course 48 

"        "  duration 51 


Insanity ,  of  termination ...  32 
'•         "  complications.  52 
"         "  prognosis  ....   54 
Insanity,  pathological  an- 
atomy     57 

Insanity,  generalized. ..  .145 
Insanity,  partial  or  system- 
atized   212 

Insomnia 79 

Intermissions 51 

Intermissions,      responsi- 
bility in 634 

Intervals,  lucid 51 

"            "      responsi- 
bility in 634 

Intoxications,    insanity 

from 485 

Involution,  lesions  of  . .  .323 
lophobia 260 


Jacoby 26 

Jealous  insanity 232 

Jennings 512,  517 

Joffroy 352,  377,  483 

K 

Kahlbaum 186 

Kaleidoscopic     hallucina- 
tions  478 

Kandinsky 67 

Keraval  and  Nercara 602 

Kiernan 389 

King 480 

Kinnier 389 

Kleptomania 276 

Koppen 103,   352 

Kovalewsky 577,  590 

Krcepelin 372,  377,  380 

Kralft-Ebingl22,  279,  288,  296 
Kussmau  ] 324 


686 


INDEX. 


Lacaille 498 

Lacassagne 307 

Lactation,  insanity  of . . .  .344 

Ladame 377 

Lailler 603 

LallementandMabille. . .  .409 

Laaccreaax 392,  495,  521 

Lande 339 

Landouzy 483, 

Langermann 26 

Lannelongue 316,  322 

Launois 117 

Lasfcgue.  .28,  214,  224,  352, 

415,  426,  488 

Las^gue  and  Falret 304 

Laurent  (A.) 664 

Laurent  (Emile) 118 

Laveran 378 

Lecorche 409 

Legoy  t  and  Ogle 42 

Legrain.. 496,518 

Legrand  du  Saulle.  ..262, 

288,  296,  304,  410,  461 

Loiter 582 

Leloyer 17 

Lelut 45 

Lcmoine..378,381,400,401,405 

Lemoine  and  Belle 182 

Lemoine  and  Cliaumier.  ..378 
Lemoine   and   Huyghes, 

398,  403 

Lepois,  Nicholas 17 

Leudet  (Lucien) 382 

Leuret 407 

Lichtwitz 281 

Liebmann 296 

Liegeois 634 

Lierseux,  colony  of 563 

Linas 415 

Litigious  insane 296 

Liver,  disease  of 358 

Loiribroso 305 

LoiTy 20,  409 


Lucas 618 

Lucid  intervals 50 

Lunier 415 

Lunar    phases,    influence 

of 41 

Lutaud 634 

Luys 253,  314 

Lypemauia     (see     melan- 
cholia)  170 

M 

Mabille 435 

Mabille     and     Lallement, 

403,  409 

MacDonald 533 

Magnan,    122,     131,     213, 

253,  277,  288,  392 

Magnan  and  Charcot 274 

Magnan  and  Saury 520 

Mairet 102,  333,  377 

Maladies,  incidental 53 

Mandragora 8 

Maniacs,  crimes  of 642 

Mania,  acute 146 

"      subacute 157 

"      hyperacute 162 

"      chronic 165 

"      remittent,  &c 166 

Manouvrier 307 

Marandon  de  Monty  el,  304, 
371,  375 

Marc 28 

Marce,  28,  32,  96,  341,  436, 

456,  477 

Marchal  de  Calvi 410 

Marechal 407 

Marriages,  of  insane,  &C.621 

Marro 103 

Martin  (Raymond) 483 

Mask,  paralytic 432 

Massotherapy 590 

Maudsley 627 

Measles,  insanity  connect- 
ed with .369 


INDEX. 


687 


Medico-legal  practice. . .  .637 

Melauciioiia 170 

varities  of. .  ..170 
Melancholiacs,  crimes  of. 643 

Mendel 103 

Menopause,  insanity  of.. 345 

Menstruation 338 

Mescbede 371 

Mesnet 407 

Metallotherapy 867 

Metz 377 

Meynert 483 

Mickle  (W.  J.)  80,  366,  388 

390,  455 
Myers  (A.    T.)  and  Percy 

Smith 575 

Mierzejewski . .  .445 

Migrators  (insane) 836 

Misdemeanors 637 

Misophobia 367 

Moment,  lucid 50 

Monoideism 358 

Monophobia 373 

Monstrosities 134,  307 

Montaigne 17 

Montigya 661 

Moon,  phases  of 41 

Moral  insanity 304 

Moral  treatment 571 

Moreau(de  Tours).. 477,   618 
Moreau  (de  Tours)  Paul.  .531 

Moreaux 498 

Morel,    37,    131,  313,    355, 

383,  388,  487 

Morel,  Jules 133 

Morel -Lavallee  and  Belieres, 

388,  395 

Morgagni 30 

Morphinism 511 

Morphinomacia 513 

Morselii,  78,  100,   136,   353, 

387 

Morselii  and  Buccola 181 

Motet 395 


Mobility,  disorders  of ... .  89 

Mystics,  insanity  of 339 

M3^stics 301 

Myxoedema 333 

Myxoedematous  idiocy. .  .  331 

N 

Nasse 26,  497 

Xegroes,  insanity  in. ... ;  34 

jSTercam  and  Keraval 603 

jSTervous  system,    insanity 

in  diseases  of 414 

Neurasthenias,  246 ;  gener- 
alities, 346;  cerebral, 
348 ;  on  impulsive  obes- 
sions,  358;  on  aboulic 
obessions,     880  ;     acute, 

347;  and  arthritism 403 

Neurosis,  insanities  due  to.  467 

Newington  (Hayes) 389 

Mewt 586 

Nicotinism . . , 530 

Nomenclature,  internation- 
al  135 

Noorden,  van 98,  110 

Non-restraint 568 

Nosophobia 371 

Nutrition,  disorders  of.  .  .  96 


O 


Obersteiner 575 

Objects,  fear  o" 367 

Obsessions,    348,  358;   im- 
pulsive, 274;  aboulic.  .380 
Oculo-pupillary    disorders 
in  general  paralysis. . .  .438 

Ogle  and  Legoyt 43 

Oniomania 278 

Oneiric  hallucinations. . ,  .303 

Onomatomania 374 

Ord 323 

Originality 243 

Oxy-carbonism 531 


688 


INDEX. 


Pachoud 98,  110 

Paludism,  insanity  from. 378 
Paralysis,  general,  414 ;  def- 
initions, 414 ;  liistory, 
414:  paralytic  dementia, 
419 ;  prodomic,  419 ;  first 
stage,  425 ;  second  stage, 
431;  terminal  stage,  432; 
insanity  of,  438 ;  expres- 
sive, 439;  melanclioliac, 
depressive,  hypochon- 
driac, 440;  latent,  444; 
course,  duration,  termina- 
tion, 443 ;  ascending,  443 ; 
pathological  anatomy, 
444;  diagnosis,  448;  eti- 
ology, 453 ;  treatment, 
461  ;  conjugal ,  4  5  8; 
syphilitic,  460 ;  prema- 
ture or  precocious,  456; 
late,  senile  or  atheromat- 
ous, 456 ;  crimes,  &c. ,  in.  467 

Paralj^sis,  pseudo-general, 
pellagrous,  387;  syphil- 
itic, 391;  alcoholic,  497; 
saturnine,  507  ;  diag- 
nosis   509 

Paralytic  dementia.  .419,  438 
Paranoia,    217;  secondary, 
218 ;    rudimentary,    137 ; 

primary  218 

Parant 388,  482 

Parchappe 28,  415 

Passions  (general  etiology),  44 
Pathophobia     (in      noso- 
phobia)  271 

Paul  of  Egina 16 

Pellagra,  insanity  of 386 

Pellagrous  general  paral- 
ysis  387 

Peretti 480 

Perfect 415 


Persecutors,  insane,  226 ; 
persecuted,  222;  ambi- 
tious, 234 ;  litigious,  296 ; 
I  erotic  and  jealous,  297; 
I  mystic,  301;  political.... 303 
I  Persecution,  insanity  of, 
j     or  Lasegue's  disease. .  .221 

I  Pertyphic  insanitv 371 

jPetei- .\..382,  482 

I  Phlebotoni}^ 

Phrenasthenias,  287 :  delu- 
sional, (delire  des  degen- 
eres),  289;  reasoning, 
(moral  insanity),  304;  in- 
stinctive, (criminal  psy- 
chosis), 305;  political... 303 

Phrenitis 6 

Phthisis,  insanity  of 381 

Physiological  states,  insan- 
ity associated  with 331 

jPichon 512,  518 

Pick 377 

Pien-et 110,  352,  376.  465 

Piuel 2,  23,  24,  25 

Pitres 295 

Places,  fear  of 270 

Planes 458 

Plater,  Felix 17 

Poincarre  and  Bonnet. . .  .447 

Political  insanity 232 

Political    events    (general 

etiology) 37 

Popofe 447 

Post-typhic  insanity 372 

Potamophobia 270 

Pottier 296 

Pulse  in  insanity 94 

Practice,  medical,  in  insan- 
ity, 522;  medico-legal... 627 

Pre-delusional  period  of 
general  paralysis 420 

Pregnancy,  insanity  of. .  .340 
Preparalytic  period  of  gen- 
eral paralysis 419 


INDEX. 


689 


Professions  (general  etiol- 
ogy)   43 

Prognosis  of  insanity ....   54 
Propensities  (obsessions) . .  274 

Prost 360 

Psyclio-motor    hallucina- 
tions   66 

Puberty,  insanity  of 331 

Puerperal    insanity,    340; 

crimes  in  646 

Purgatives  in  treatment  of 

insanity 599 

Pussin 23 

Pyromania 277 

Q 

Querulanten  -  Wahnsinn, 
(see  litigious  insanity) . .  296 

R 

Race  (general  etiology). . .  33 
Rabies,  insanity  connected 

with 376 

Reports,  medico-legal 666 

Raymond 352 

Recovery 52 

Relapses  in  insanity 56 

Reflexes,  disorders  of,  86; 
in    general    paralysis,   421 

Regicides 303 

Regis 100,  303 

Regis  and  Arnozan 100 

Regis  and  Ball 404 

Regis  and  Friese 462 

Reiuhardt 98 

Religious  insanity 229 

Religious     ideas    (general 

etiology) 37 

Remissions,    50 ;    responsi- 
bility in,  634 ;  in  general 
paralysis,    444;   in  alco- 
holic pseudo-paralysis .  502 
Renaissance 2,  17 


Rendu 488 

Requin 415 

Respiration,  disorders  of  in 

insanity 95 

Responsibility,  penal,  of 
the  insane,  628;  partial 
or  attenuated,  628 ;  in  re- 
missions, intermissions 
and  lucid  intervals. . .  .634 

Reverdin 592 

Revulsion 592 

Rhazes 16 

Rheumatism,  insanity  con- 
nected with 406 

Ribot 74,  137,  255,  258 

Riel 302 

Ritti 191 

Ritti  and  Christian 458 

Riva 288 

Robinson 321 

Roger 482 

Rougier 465 

Rouillard 403 

Rousset 499 

Ru  pophobia      or     m  i  s  o  - 

phobia 267 

Rush 28,  376 


Salgo 582 

Sander 288,  291 

Sandon 294 

Sandras 415 

Santos,  de 410 

Saturnism,  insanity  from .  503 
Saturnine     insanity    (sub- 
acute)  505;    acute,    505; 
hyperacute,  506 ;  dement- 
ia,   507;    pseudo-general 

paralysis 507 

Saury 520 

Saury  and  Magnan 520 

Sauvages 20 


690 


ENDEX. 


Sauze  and  Aubanel 412 

Savage.... 389,  394,  483,  519 
Scarlatina,  insauit}'  irom.369 

Schlager 371 

Schroeder  van  der  Kolk, 

26,  381 

Schlile 384 

Sclerosis,  multiple  (mental 
state  in)  460;  diagnosis 
of,     466;    with    general 

paralysis 466 

Seasons  (general  etiology)  41 

Sebastian 378,  380 

Secretions  (disorders  of)  in 
the  insane,  97 ;  salivary, 
97;  gastric,  98;  biliary, 
99;  sudral,  99;  sebace- 
ous  100 

Seglas...67,  82,  220,  284,  520 

Seglas  and  Chaslin 186 

Seguiu 815 

Semal  (of  Mons) 46 

Senac 409 

Senile  insanity 335 

Sennert 17 

Sensibility,  (disorders  of) 
in  the  insane,  80;  cuta- 
neous, 80;  electric,  82; 
magnetic,  82;  metallic, 
82;  meteoric,  82;  gusta- 
tory, 83;  olfactory,  83; 
auditory,  83;  visual,  84; 
muscular,  b4;  organic, 
86 ;  in  general  paralysis.  429 

Seppilli 439 

Sequestration  (medical  opin- 
ion as   to   need   of)  551 ; 
motives  of,  548 ;  of  dan- 
gerous lunatics 551 

Sergi 307 

Sex  (general  etiology) ....  41 
Sexual  relations  of  the  in- 
sane  610 

Shaw 462 

Simon 407 


Simon  (Max) 627 

Simson 407 

Simulated   insanity 658 

Simultaneous  insanity  {folie 

d  aeux) 292 

Sitophobia,    98;  in   acute 

melancholia 175 

Skae 881,  388 

Skae  and  Clouston 388 

Skatophagia 76 

Skin,  in  the  insane 99 

Sleep,  (disorders  of)  in  the 

insane 79 

Smith,   Percy,  and  A.  T. 

Myers 575 

Smyth,  Johnson 101 

Snell 296 

Soibrig 35 

Sollier 311 

Soranus  of  Ephesus 13 

Speech,  embarrassment  of 

in  general  paralysis. . .  .425 
Sphincters,  relaxion   of  in 

general  paralj^sis 432 

Spinal    cord,    insanity  in. 465 

diseases  of 465 

Spitzka 334 

Stahl 25 

Stewart,  Grainger 388 

Stigmata,  psychic,  112; 
physical,  118;  stomach, 

lavage  of 

Strambio 386 

Strump  riva,  cachexia.  .322 
Stupor,  melancholia  with.  185 
Suette,  miliary,  insanity  in.  369 
Suggestion,   in  treatment 

of  insanity 574 

Suicide  in  acute  melan- 
cholia, 175;  in  neuras- 
thenia, 278 ;  indirect 643 

Suigical  treatment  of  in- 
sanity   

Svetlin 582 

Swedenborg 302 


INDEX. 


691 


Sydenham 18,  378,  409 

Sylvius  de  la  Boe 17 

Sympathetic  (causes)  gen- 
eral etiology,  47 ;  insan- 
ities, 145,  328,  331. 
Syphilis  (insanity  connect- 
ed with)  388 ;  and  gen- 
eral paralysis 392 

Systematized  insanity,  pro- 
*^gressive,  132;  original.. 291 


T 


Tabetic  insanity 465 

Taguet 297 

Tamburini 66,  252,  255 

Tanquerel    des    Planches, 

504,  507 

Tauret 609 

Tarde 307,  637 

Tardieu 

Targowla 447 

Teissier 403 

Temperature  in  insanity . .  104 

Thyroidectomy 592 

Thyroid  grafting 322 

Tics,  convulsive 275 

Tigges 585 

Todd 409 

Tonnini... 288 

Toucher,  delire  du 262 

Toxic      insanities,       485  ; 

crimes,  &c. ,  in 647 

Treatment  of  insanity,  559 ; 
preventive,  559;  curat- 
ive, 560;  in  a  special 
hospital,  561 ;  in  farm 
colonies  (family  system) 
562 ;  in  country  houses, 
564;  in  water  cures,  562; 
by  travel.  566 ;  by  non-re- 
straint, 568;  by  hygienic 
agents,  569;  by  psychic 
agencies,  (moral  treat- 
ment) 571;     suggestive, 


574;  by  physical  agencies 
(hydrotherapy  576;  elec- 
trotherapy) 576 ;  by  sur- 
gical agencies  (trephin- 
ing, cerebrotomy,  crani- 
ectomy) 591;  revulsion, 
592 ;  thyroidectomy,  592 ; 
thyroid  grafts,  592;  cas- 
tration, 593;  clitoridect- 
omy,  593;  bleeding, 
transfusion,  594;  hypo- 
dermic injections,  594: 
lavage  of  stomach,  595; 
by  pharmaceutical 
agents  (purgatives,  599; 
sedatives  and  hypnotics, 
600;  tonics,  antiperiod- 
ics,  emmenagogues,  600 ;) 
therapeutic  formulary. 601 
Transfusion  of  blood. . .  .594 

Trelat 27 

Tremor  in   general  paraly- 
sis  , 426 

Trephining 591 

Tricophobia 267 

Trophic  disorders,    in  the , 
insane,   105;    in  general 

paralysis 433 

Trousseau 412 

Tuberculosis 381 

Tuczek 447 

Tuke  (William) 24,  105 

Tuke  (Hack) 122 

Tuke  ahd  Bucknill 122 

Tuke  (Batty) 462 

Typhoid    fever,    insanity 
in 370 

U 

Unilateral  hallucinations.  66 

Uraemia  (delirious) 352 

Urine  in  the  insane 102 

Utero  ovarian  insanit3^.  .348 
Untidy  patients 570 


692 


INDEX. 


Vessels,  psychic  disorders 

iu  diseases  of 365 

Vaisselle 403 

Vallou 435 

Van  Swieten 19 

Variola,  insanity  from. .  .367 
Vaso-motor  disorders  in  in- 
sanity   105 

Vegetative  functions,  dis- 
orders of 73 

Velocipeding 590 

Verga 270 

Vering 26 

Verminous  insanity 359 

Verneuil ' 412 

Vesanias 139 

Vetault 634 

Vieussens 19 

Vigouroux 287 

Viscera,  insanity  from  local 

disease  of 348 

Vix 3G1 

Vizipli 575 

Voisin  (Felix) 27,  315 

Voisin  (Auguste)  83,  575, 

594,  664 
Voyages 566 


W 

Wars  (general  etiology). .  .   37 

Weir-Mitchell 286 

Westphal 270 

Wichmann 356 

Wier 17 

Wiglesworth 350 

Wille 308 

Willis 18 

AVinternitz 582 

Woelcken 521 

Wolf 94 

Writing  of  insane,  93 ;  in 
general  paralysis,  ....  427 


Yvon 601,  602 

Z 

Zacchias,  Paul 17 

Zambaco 392 

Ziehen 81 

Zoophobia 274 


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